Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | LAT-3766 | NC |
Y | 213ES0000X | Sports Medicine | LAT-3766 | NC |
NPI | 1154813756 |
---|---|
Provider Name | Mr. Willie Phillips II |
First Address | Charlotte, NC 28274-0001 |
Second Address | Charlotte, NC 28274-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/05/2018 |
Last Update Date | 31/05/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2000008378 | NATABOC (01) | CA |
LAT-3766 | NORTH CAROLINA BOARD OF ATHLETIC TRAINER EXAMINERS (01) | NC |