Provider Demographics
NPI:1114358033
Name:PHELPS, GRAHAM A (FNP-BC)
Entity Type:Individual
Prefix:
First Name:GRAHAM
Middle Name:A
Last Name:PHELPS
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:
Practice Address - Street 1:16180 SE SUNNYSIDE RD STE 102
Practice Address - Street 2:
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97015-6302
Practice Address - Country:US
Practice Address - Phone:503-582-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-02
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-011006363LF0000X
OR201600270NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily