Provider Demographics
NPI:1275286379
Name:PHELPS, BRENDAN
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:
Last Name:PHELPS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4695 CENTAURI RD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-3115
Mailing Address - Country:US
Mailing Address - Phone:813-774-0947
Mailing Address - Fax:
Practice Address - Street 1:1725 E BOULDER ST STE 101
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5740
Practice Address - Country:US
Practice Address - Phone:719-365-6300
Practice Address - Fax:719-365-6094
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-28
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program