Provider Demographics
NPI:1619700481
Name:RODGERS, PHILLIP ERIC (FNP-C)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:ERIC
Last Name:RODGERS
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13418 ATTALA ROAD 4101
Mailing Address - Street 2:
Mailing Address - City:SALLIS
Mailing Address - State:MS
Mailing Address - Zip Code:39160-5242
Mailing Address - Country:US
Mailing Address - Phone:601-613-7835
Mailing Address - Fax:
Practice Address - Street 1:332 HIGHWAY 12 W
Practice Address - Street 2:
Practice Address - City:KOSCIUSKO
Practice Address - State:MS
Practice Address - Zip Code:39090-3209
Practice Address - Country:US
Practice Address - Phone:662-289-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS906890363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily