Provider Demographics
NPI:1447201389
Name:PHELPS, DOUGLAS (PA-C)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:PHELPS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:DOUG
Other - Middle Name:
Other - Last Name:PHELPS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 67250
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-7250
Mailing Address - Country:US
Mailing Address - Phone:402-328-2907
Mailing Address - Fax:888-965-0959
Practice Address - Street 1:4210 PIONEER WOODS DR STE A
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-7561
Practice Address - Country:US
Practice Address - Phone:402-488-4321
Practice Address - Fax:402-488-4355
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61178665363A00000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC802010Medicare PIN