Healthcare Provider Details

I. General information

NPI: 1831273614
Provider Name (Legal Business Name): GARY PHELPS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 03/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

759 CHESTNUT ST
SPRINGFIELD MA
01199-1001
US

IV. Provider business mailing address

280 CHESTNUT ST 2ND FLOOR
SPRINGFIELD MA
01199-1000
US

V. Phone/Fax

Practice location:
  • Phone: 413-794-5550
  • Fax: 413-794-9294
Mailing address:
  • Phone: 413-794-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number555
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: