Provider Demographics
NPI:1073132817
Name:PHELPS, ELIZABETH CARRIE (PA-C)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:CARRIE
Last Name:PHELPS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:CARRIE
Other - Last Name:COLLUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3231 S NATIONAL AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-7304
Mailing Address - Country:US
Mailing Address - Phone:417-820-8450
Mailing Address - Fax:
Practice Address - Street 1:3231 S NATIONAL AVE STE 220
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7304
Practice Address - Country:US
Practice Address - Phone:417-820-8450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-12
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021000070363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty