Provider Demographics
NPI:1073753638
Name:PHILLIPS, CARLY FERGUSON (PA-C)
Entity type:Individual
Prefix:MISS
First Name:CARLY
Middle Name:FERGUSON
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:
Other - Last Name:FERGUSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:825 NE 10TH ST STE 1C
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-5417
Mailing Address - Country:US
Mailing Address - Phone:405-271-4426
Mailing Address - Fax:405-271-6762
Practice Address - Street 1:825 NE 10TH ST STE 1C
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5417
Practice Address - Country:US
Practice Address - Phone:405-271-2663
Practice Address - Fax:405-271-3074
Is Sole Proprietor?:No
Enumeration Date:2009-02-23
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01744363A00000X
OH50.004349RX363A00000X
OK4708363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant