Provider Demographics
NPI:1003614165
Name:ELLEDGE, LAYTON PAUL
Entity type:Individual
Prefix:
First Name:LAYTON
Middle Name:PAUL
Last Name:ELLEDGE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4210 N EDWARDS ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-4004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4605 NW 23RD ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73127-2128
Practice Address - Country:US
Practice Address - Phone:405-978-2220
Practice Address - Fax:405-978-2221
Is Sole Proprietor?:No
Enumeration Date:2025-03-05
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program