Basic Information
| Provider Information | |||||||||
| NPI: | 1407126394 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHELAN | ||||||||
| FirstName: | LEILANI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OTERO | ||||||||
| OtherFirstName: | LEILANI | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 15320 AMBERLY DR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336471647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139770733 | ||||||||
| FaxNumber: | 8139712230 | ||||||||
| Practice Location | |||||||||
| Address1: | 15320 AMBERLY DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336471647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139772090 | ||||||||
| FaxNumber: | 8139779107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2012 | ||||||||
| LastUpdateDate: | 05/15/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA9106375 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | PA9106375 | 01 | FL | STATE LICENSE | OTHER |