Provider Demographics
NPI:1477690899
Name:PHELPS, PAULA BRUTZ (PA)
Entity Type:Individual
Prefix:MRS
First Name:PAULA
Middle Name:BRUTZ
Last Name:PHELPS
Suffix:
Gender:F
Credentials:PA
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 4908
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83205-4908
Mailing Address - Country:US
Mailing Address - Phone:208-236-1600
Mailing Address - Fax:208-209-1027
Practice Address - Street 1:1151 HOSPITAL WAY
Practice Address - Street 2:SUITE D, SUITE 201
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5091
Practice Address - Country:US
Practice Address - Phone:208-478-2472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-166363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPAJ81OtherBCS
ID004392500Medicaid