Provider Demographics
NPI:1114598042
Name:BASE, ELISE NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:NICOLE
Last Name:BASE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 48TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-3948
Mailing Address - Country:US
Mailing Address - Phone:405-708-6000
Mailing Address - Fax:
Practice Address - Street 1:6800 PRESTON RD
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-2505
Practice Address - Country:US
Practice Address - Phone:214-473-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-01
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363A00000X
TXPA14741363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant