Provider Demographics
NPI:1528248903
Name:PHILLIPS, JEANNINE PAMELA (PA-C)
Entity type:Individual
Prefix:
First Name:JEANNINE
Middle Name:PAMELA
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 LILAC DR N STE 190
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4544
Mailing Address - Country:US
Mailing Address - Phone:763-267-8701
Mailing Address - Fax:
Practice Address - Street 1:1415 LILAC DR N STE 190
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-4544
Practice Address - Country:US
Practice Address - Phone:763-267-8701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-14
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10348363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP85889OtherHEALTH PARTNERS
MN154N5PHOtherBCBSM
MNP00474995OtherRR MEDICARE
MN139989OtherUCARE
MN178452100Medicaid
MN139989OtherUCARE