Provider Demographics
NPI:1548523459
Name:JOHN, PHILLIP (LMP)
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:
Last Name:JOHN
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4325 113TH PL NE UNIT B
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98271-8302
Mailing Address - Country:US
Mailing Address - Phone:360-319-9349
Mailing Address - Fax:
Practice Address - Street 1:4325 113TH PL NE UNIT B
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98271-8302
Practice Address - Country:US
Practice Address - Phone:360-319-9349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024848225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist