Provider Demographics
NPI:1255912127
Name:DYSON, ELLE KARLI (PA-C)
Entity type:Individual
Prefix:MS
First Name:ELLE
Middle Name:KARLI
Last Name:DYSON
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 1:525 WESTERN AVE STE 305
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-4982
Mailing Address - Country:US
Mailing Address - Phone:501-358-6145
Mailing Address - Fax:501-504-6642
Practice Address - Street 1:525 WESTERN AVE STE 305
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-4982
Practice Address - Country:US
Practice Address - Phone:501-358-6145
Practice Address - Fax:501-504-6642
Is Sole Proprietor?:No
Enumeration Date:2010-09-03
Last Update Date:2024-07-10
Deactivation Date:2020-11-09
Deactivation Code:
Reactivation Date:2021-04-20
Provider Licenses
StateLicense IDTaxonomies
ARPA977363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR268244795Medicaid