Provider Demographics
NPI:1689676462
Name:PHELPS, GARY (CRNA)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:PHELPS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10508 CHESHAM WAY
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:MD
Mailing Address - Zip Code:21163-1364
Mailing Address - Country:US
Mailing Address - Phone:410-465-2449
Mailing Address - Fax:410-465-2573
Practice Address - Street 1:2411 W BELVEDERE AVE
Practice Address - Street 2:MID ATLANTIC NEURO ASSOCIATES
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5228
Practice Address - Country:US
Practice Address - Phone:410-601-8314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR130008367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD649100600Medicaid