Provider Demographics
NPI:1902282221
Name:CHANG, PHILIP (RN, CNS)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:RN, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4515 SETON CENTER PKWY STE 215
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-5785
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1201 W 38TH ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1006
Practice Address - Country:US
Practice Address - Phone:512-324-1864
Practice Address - Fax:512-419-9016
Is Sole Proprietor?:No
Enumeration Date:2015-08-10
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP128753364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX466748YLP1OtherMEDICARE SAIMS TRAVIS
TX354374602OtherMEDICAID SAIMS TRAVIS
TX466748YLP2OtherMEDICARE SAIMS ROT
TX354374601OtherMEDICAID SAIMS ROT