Provider Demographics
NPI:1457879975
Name:PHELAN, MARK AARON (RN)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:AARON
Last Name:PHELAN
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:779 S TENNYSON WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-7738
Mailing Address - Country:US
Mailing Address - Phone:208-724-1829
Mailing Address - Fax:208-724-1829
Practice Address - Street 1:779 S. TENNYSON WAY
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709
Practice Address - Country:US
Practice Address - Phone:208-724-1829
Practice Address - Fax:208-724-1829
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN-29179163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDM8070381Medicaid
IDM8071148Medicaid