Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 8069 | TX |
NPI | 1114164613 |
---|---|
Provider Name | Dr. Michael Wayne Phillips |
First Address | Arlington, TX 76011-4510 |
Second Address | Arlington, TX 76011-4510 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/01/2009 |
Last Update Date | 21/01/2009 |