MEDICARE: MR. SAMMIE L PHELAN PHYSICIAN ASSISTANT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	009823	NY

General Provider Information

NPI Number	:	1649245796
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SAMMIE L PHELAN PHYSICIAN ASSISTANT

Provider Business Mailing Address
First Line	:	14020 N 46TH ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33613-4018
Country	:	US
Telephone Number	:	813-972-2000
Fax Number	:	813-972-7605

Provider Business Practice Location Address
First Line	:	14020 N 46TH ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33613-4018
Country	:	US
Telephone Number	:	813-972-2000
Fax Number	:	813-972-7605

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2006
Last Update Date	:	09/29/2011

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