Provider Demographics
NPI:1093795114
Name:ELLEDGE, ASHLEY ELIZABETH (PAC)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:ELIZABETH
Last Name:ELLEDGE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:ELIZABETH
Other - Last Name:ELLEDGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1127 S GEORGE NIGH EXPY
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-7143
Mailing Address - Country:US
Mailing Address - Phone:918-423-8440
Mailing Address - Fax:
Practice Address - Street 1:1127 S GEORGE NIGH EXPY
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-7143
Practice Address - Country:US
Practice Address - Phone:918-423-8440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1511363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant