Provider Demographics
NPI:1982636809
Name:ELLIS, PATRICK BOONE (DO)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:BOONE
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 24TH AVE S.W.
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-5106
Mailing Address - Country:US
Mailing Address - Phone:405-701-5666
Mailing Address - Fax:405-701-5667
Practice Address - Street 1:226 W GRAY ST STE 214
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-7132
Practice Address - Country:US
Practice Address - Phone:405-701-5666
Practice Address - Fax:405-701-5667
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3351174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100138180BMedicaid
OKG60360Medicare UPIN