Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | 2697 | MN |
NPI | 1659424919 |
---|---|
Provider Name | Dr. Lavern A Phelps JR. |
First Address | Ely, MN 55731-1228 |
Second Address | Ely, MN 55731-1228 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/01/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
231027 | CHIROCARE (01) | MN |
62523PL | BCBSMN (01) | MN |
U02799 | (02) | MN |