Provider Demographics
NPI:1154799070
Name:PHILLIPS, ALISON LEIGH (PA-C)
Entity type:Individual
Prefix:
First Name:ALISON
Middle Name:LEIGH
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALISON
Other - Middle Name:LEIGH
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 1847
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49443-1847
Mailing Address - Country:US
Mailing Address - Phone:231-672-8145
Mailing Address - Fax:231-672-6179
Practice Address - Street 1:1560 E SHERMAN BLVD STE 250
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1854
Practice Address - Country:US
Practice Address - Phone:231-672-8145
Practice Address - Fax:231-672-6179
Is Sole Proprietor?:No
Enumeration Date:2015-09-09
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007485363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N94150OtherMEDICARE GROUP PTAN
MI0N34010OtherMEDICARE GROUP PTAN