=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407670011
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PIERSON PHELAN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2024
-----------------------------------------------------
Last Update Date | 11/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 275 BLOMQUIST ST
-----------------------------------------------------
City | REDWOOD CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94063-2714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-512-4038
-----------------------------------------------------
Fax | 877-883-6503
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3800 KILROY AIRPORT WAY STE 270
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90806-2497
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172V00000X
-----------------------------------------------------
Taxonomy Name | Community Health Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------