Provider Demographics
NPI:1649239278
Name:PHELAN, PAMELA J (PAC)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:J
Last Name:PHELAN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:J
Other - Last Name:CROSSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6958 SW VARNS STREET
Mailing Address - Street 2:SOUTHWEST DIAGNOSTIC IMAGING, LTD
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-2530
Mailing Address - Country:US
Mailing Address - Phone:503-683-7730
Mailing Address - Fax:039-140-9275
Practice Address - Street 1:6958 SW VARNS STREET
Practice Address - Street 2:SOUTHWEST DIAGNOSTIC IMAGING, LTD
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-2530
Practice Address - Country:US
Practice Address - Phone:503-683-7730
Practice Address - Fax:039-140-9275
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33022085R0202X
ORPA203665363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ035547Medicaid
AZZ107460Medicare PIN
AZZ107459Medicare PIN
Q60970Medicare UPIN