Healthcare Provider Details

I. General information

NPI: 1225058266
Provider Name (Legal Business Name): LARRY C. PHILLIPS II P.A.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 05/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 E PINEY FOREST RD
DANVILLE VA
24540
US

IV. Provider business mailing address

441 E PINEY FOREST RD
DANVILLE VA
24540
US

V. Phone/Fax

Practice location:
  • Phone: 434-791-4110
  • Fax:
Mailing address:
  • Phone: 434-791-4110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number102445
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110003402
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: