Provider Demographics
NPI:1801824917
Name:PHELAN, WILLIAM JORDAN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:JORDAN
Last Name:PHELAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9601-20 MICCOSUKEE RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32309-9662
Mailing Address - Country:US
Mailing Address - Phone:850-878-0191
Mailing Address - Fax:850-219-2704
Practice Address - Street 1:VA CLINIC, 1607 ST JAMES COURT
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308
Practice Address - Country:US
Practice Address - Phone:850-878-0191
Practice Address - Fax:850-219-2704
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA 9103039363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP09869Medicare UPIN