Provider Demographics
NPI:1740078179
Name:FAXON, ELLIE MARIE (PA)
Entity type:Individual
Prefix:
First Name:ELLIE
Middle Name:MARIE
Last Name:FAXON
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:343 S FARM ROAD 97
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-9270
Mailing Address - Country:US
Mailing Address - Phone:970-818-6938
Mailing Address - Fax:
Practice Address - Street 1:1499 N ROBBERSON AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-1979
Practice Address - Country:US
Practice Address - Phone:417-269-2667
Practice Address - Fax:417-269-2668
Is Sole Proprietor?:No
Enumeration Date:2025-04-26
Last Update Date:2025-04-26
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant