Basic Information
Provider Information | |||||||||
NPI: | 1023090487 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PHILLIPS | ||||||||
FirstName: | GLENN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 17360 BROOKHURST ST | ||||||||
Address2: | ATTN: CREDENTIALING DEPARTMENT | ||||||||
City: | FOUNTAIN VALLEY | ||||||||
State: | CA | ||||||||
PostalCode: | 927083720 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6572413592 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 23512 MADERO | ||||||||
Address2: |   | ||||||||
City: | MISSION VIEJO | ||||||||
State: | CA | ||||||||
PostalCode: | 926912743 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9495831600 | ||||||||
FaxNumber: | 9494548067 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/18/2005 | ||||||||
LastUpdateDate: | 05/26/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA 10513 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | PA10513 | 05 | CA |   | MEDICAID |