Provider Demographics
NPI:1548448087
Name:ELLIS, STACY LUANN (PA)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:LUANN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:448 36TH AVE NW STE 101
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-4743
Mailing Address - Country:US
Mailing Address - Phone:405-573-9905
Mailing Address - Fax:
Practice Address - Street 1:448 36TH AVE NW STE 101
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-4743
Practice Address - Country:US
Practice Address - Phone:405-573-9905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-06
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-01282363A00000X
OK1724363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK400033Medicare PIN