Provider Demographics
NPI:1225634058
Name:ELDER, MARIELLE YSABEL (PA-C)
Entity Type:Individual
Prefix:
First Name:MARIELLE
Middle Name:YSABEL
Last Name:ELDER
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 1:700 NE 13TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-5004
Mailing Address - Country:US
Mailing Address - Phone:405-271-9440
Mailing Address - Fax:
Practice Address - Street 1:700 NE 13TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5004
Practice Address - Country:US
Practice Address - Phone:405-271-9440
Practice Address - Fax:405-271-6091
Is Sole Proprietor?:No
Enumeration Date:2020-12-07
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4434363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant