Provider Demographics
NPI:1487711636
Name:PHELAN, SUSAN (PH D NP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:PHELAN
Suffix:
Gender:F
Credentials:PH D NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 MAIN STREET
Mailing Address - Street 2:SUITE G
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777
Mailing Address - Country:US
Mailing Address - Phone:631-760-1830
Mailing Address - Fax:631-509-6080
Practice Address - Street 1:1000 MAIN STREET
Practice Address - Street 2:SUITE G
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777
Practice Address - Country:US
Practice Address - Phone:631-760-1830
Practice Address - Fax:631-509-6080
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYF4001481363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01570447Medicaid
NY01570447Medicaid
NYS46418Medicare UPIN