Provider Demographics
NPI:1225327422
Name:PHELAN, NATHANIEL M (MD)
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:M
Last Name:PHELAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 E 32ND ST
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-3904
Mailing Address - Country:US
Mailing Address - Phone:417-622-0293
Mailing Address - Fax:833-275-1784
Practice Address - Street 1:520 E 32ND ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3904
Practice Address - Country:US
Practice Address - Phone:417-622-0293
Practice Address - Fax:833-275-1784
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-29
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018014111207ND0101X, 207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2018014111OtherDERMATOLOGY