Provider Demographics
NPI:1255727293
Name:PHILLIPS, NICHOLAS ANDREW (MD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ANDREW
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39120 ARGONAUT WAY # 275
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1304
Mailing Address - Country:US
Mailing Address - Phone:510-796-0770
Mailing Address - Fax:
Practice Address - Street 1:556 MOWRY AVE STE 200
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536
Practice Address - Country:US
Practice Address - Phone:510-796-0770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-07
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA153125207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine