Provider Demographics
NPI:1093124026
Name:ELY, PATRICK (PA)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:ELY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2577 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-5919
Mailing Address - Country:US
Mailing Address - Phone:970-247-8382
Mailing Address - Fax:970-259-4403
Practice Address - Street 1:2577 MAIN AVE
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5919
Practice Address - Country:US
Practice Address - Phone:970-247-8382
Practice Address - Fax:970-259-4403
Is Sole Proprietor?:No
Enumeration Date:2014-08-04
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA1474363A00000X
COPA.0007052363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant