Provider Demographics
NPI:1629743315
Name:MCCOY, ELISHA
Entity Type:Individual
Prefix:
First Name:ELISHA
Middle Name:
Last Name:MCCOY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2842 340TH AVE
Mailing Address - Street 2:
Mailing Address - City:CAMANCHE
Mailing Address - State:IA
Mailing Address - Zip Code:52730-9649
Mailing Address - Country:US
Mailing Address - Phone:515-664-7693
Mailing Address - Fax:
Practice Address - Street 1:1227 E RUSHOLME ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-2459
Practice Address - Country:US
Practice Address - Phone:563-421-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-13
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA118667363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical