Provider Demographics
NPI:1992241228
Name:HARDY, PHILLIP LAWERNCE SR (PA-C)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:LAWERNCE
Last Name:HARDY
Suffix:SR
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:ATTN: MEF CREDENTIALING (RM 4172)
Mailing Address - Street 2:PO BOX 555191
Mailing Address - City:CAMP PENDLETON
Mailing Address - State:CA
Mailing Address - Zip Code:92055-5791
Mailing Address - Country:US
Mailing Address - Phone:760-725-1577
Mailing Address - Fax:
Practice Address - Street 1:13 AREA BRANCH HEALTH CLINIC
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92058
Practice Address - Country:US
Practice Address - Phone:251-978-3332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-10
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1221005363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant