Provider Demographics
NPI:1760872808
Name:PHILLIPS, CHARLES HENRY III (PA)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:HENRY
Last Name:PHILLIPS
Suffix:III
Gender:M
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:1915 W PARK DR STE 103
Mailing Address - Street 2:
Mailing Address - City:NORTH WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28659-3777
Mailing Address - Country:US
Mailing Address - Phone:336-838-9553
Mailing Address - Fax:
Practice Address - Street 1:1915 W PARK DR STE 103
Practice Address - Street 2:
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3777
Practice Address - Country:US
Practice Address - Phone:336-838-9553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-28
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MT41019363A00000X
VA0110005603363A00000X
NC0010-05417363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant