Provider Demographics
NPI:1972602886
Name:PHELPS, SHAWNA LYN BULL (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAWNA
Middle Name:LYN BULL
Last Name:PHELPS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHAWNA
Other - Middle Name:LYN
Other - Last Name:BULL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:20 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28803-2493
Practice Address - Country:US
Practice Address - Phone:828-274-7502
Practice Address - Fax:828-271-6599
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2013-01236207VX0201X, 207VX0000X
TXM0025207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX171282001Medicaid
TX171282004Medicaid
OK200215610AMedicaid
TX171282003Medicaid
TXP00748698OtherRAILROAD MEDICARE
NC1972602886Medicaid
TX8AQ004OtherBCBSTX
FLP01267093OtherRAILROAD MCR
TX171282004Medicaid
TX8AQ004OtherBCBSTX
TX171282001Medicaid
TX8K7906Medicare PIN