Provider Demographics
NPI:1326237850
Name:JAN D. PHELPS, PA
Entity Type:Organization
Organization Name:JAN D. PHELPS, PA
Other - Org Name:ABBEY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAN
Authorized Official - Middle Name:DENICE
Authorized Official - Last Name:PHELPS
Authorized Official - Suffix:
Authorized Official - Credentials:ARNPC
Authorized Official - Phone:813-931-9094
Mailing Address - Street 1:1442 W BUSCH BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-7602
Mailing Address - Country:US
Mailing Address - Phone:813-931-9094
Mailing Address - Fax:813-935-1126
Practice Address - Street 1:1442 W BUSCH BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-7602
Practice Address - Country:US
Practice Address - Phone:813-931-9094
Practice Address - Fax:813-935-1126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1851392363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY031BOtherBCBS
FLP62395OtherUPIN
FL1851392OtherLICENSE
FL305568000Medicaid
FLE7385YMedicare Oscar/Certification
FLK7167Medicare PIN