Provider Demographics
NPI:1104904903
Name:FARRIS, PHILLIP SHANNON (PA-C, MPAS)
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:SHANNON
Last Name:FARRIS
Suffix:
Gender:M
Credentials:PA-C, MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2404 11TH ST SE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-4598
Mailing Address - Country:US
Mailing Address - Phone:256-353-2018
Mailing Address - Fax:
Practice Address - Street 1:1103 16TH AVE SE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-3595
Practice Address - Country:US
Practice Address - Phone:256-350-0362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA-262363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALPA-262OtherALABAMA LICENSE NUMBER
ALP37203Medicare UPIN