Provider Demographics
NPI:1174074991
Name:SMALL, ELYSIA (PA)
Entity type:Individual
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First Name:ELYSIA
Middle Name:
Last Name:SMALL
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Gender:F
Credentials:PA
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Mailing Address - Street 1:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:702-954-7761
Mailing Address - Fax:928-527-4327
Practice Address - Street 1:1501 S YALE ST
Practice Address - Street 2:BUILDING 2 SUITE 150
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-7304
Practice Address - Country:US
Practice Address - Phone:928-527-4325
Practice Address - Fax:928-527-4327
Is Sole Proprietor?:No
Enumeration Date:2016-10-17
Last Update Date:2024-07-25
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Provider Licenses
StateLicense IDTaxonomies
AZ6563363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical