Provider Demographics
NPI:1528481553
Name:PHELPS, ERIN O'MALLEY (PA-C)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:O'MALLEY
Last Name:PHELPS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:AILEEN
Other - Last Name:O'MALLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1635 NC HIGHWAY 66 S
Mailing Address - Street 2:STE 125
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-3854
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1635 NC HIGHWAY 66 S STE 235
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-3855
Practice Address - Country:US
Practice Address - Phone:336-992-4800
Practice Address - Fax:336-992-5160
Is Sole Proprietor?:No
Enumeration Date:2014-01-28
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-04790363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1528481553Medicaid