Provider Demographics
NPI:1699281642
Name:PHILLIPS, CLIFTON VINCENT (PA-C)
Entity type:Individual
Prefix:
First Name:CLIFTON
Middle Name:VINCENT
Last Name:PHILLIPS
Suffix:
Gender:M
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 1:12039 NE 128TH ST STE 400
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-3029
Mailing Address - Country:US
Mailing Address - Phone:206-454-9133
Mailing Address - Fax:425-392-3561
Practice Address - Street 1:12039 NE 128TH ST STE 400
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3029
Practice Address - Country:US
Practice Address - Phone:206-454-9133
Practice Address - Fax:425-392-3561
Is Sole Proprietor?:No
Enumeration Date:2017-12-28
Last Update Date:2024-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60895418363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2113108Medicaid