Provider Demographics
NPI:1518190040
Name:PHELPS, DESAREE (PA-C)
Entity Type:Individual
Prefix:
First Name:DESAREE
Middle Name:
Last Name:PHELPS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 W CARO RD
Mailing Address - Street 2:
Mailing Address - City:CARO
Mailing Address - State:MI
Mailing Address - Zip Code:48723-9686
Mailing Address - Country:US
Mailing Address - Phone:989-672-2100
Mailing Address - Fax:
Practice Address - Street 1:1525 W CARO RD
Practice Address - Street 2:
Practice Address - City:CARO
Practice Address - State:MI
Practice Address - Zip Code:48723-9686
Practice Address - Country:US
Practice Address - Phone:989-672-2000
Practice Address - Fax:989-672-2120
Is Sole Proprietor?:No
Enumeration Date:2009-09-01
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005616363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant