Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 2226 | AZ |
Y | 207QA0401X | Family Doctor - Addiction Medicine | 2226 | AZ |
NPI | 1598757114 |
---|---|
Provider Name | Wendell B Phillips |
First Address | Phoenix, AZ 85027-4171 |
Second Address | Phoenix, AZ 85027-4013 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/08/2005 |
Last Update Date | 06/03/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
268715 | (05) | AZ |
E20705 | (02) | AZ |