Healthcare Provider Details

I. General information

NPI: 1225327422
Provider Name (Legal Business Name): NATHANIEL M PHELAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2011
Last Update Date: 12/27/2024
Certification Date: 12/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 E 32ND ST
JOPLIN MO
64804-3904
US

IV. Provider business mailing address

520 E 32ND ST
JOPLIN MO
64804-3904
US

V. Phone/Fax

Practice location:
  • Phone: 417-622-0293
  • Fax: 833-275-1784
Mailing address:
  • Phone: 417-622-0293
  • Fax: 833-275-1784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2018014111
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number2018014111
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number2018014111
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: