Provider Demographics
NPI:1831191113
Name:EZELL, OLIVER LAURENCE (PA-C)
Entity type:Individual
Prefix:MR
First Name:OLIVER
Middle Name:LAURENCE
Last Name:EZELL
Suffix:
Gender:M
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 1:1504 SPRINGHILL AVE
Mailing Address - Street 2:STE 1365
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36604-3207
Mailing Address - Country:US
Mailing Address - Phone:251-405-9914
Mailing Address - Fax:251-405-5317
Practice Address - Street 1:1504 SPRINGHILL AVE
Practice Address - Street 2:STE 1365
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36604-3207
Practice Address - Country:US
Practice Address - Phone:251-405-9914
Practice Address - Fax:251-405-5317
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA-234363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL7722482OtherAETNA
ALP20387OtherHEALTHSPRING/SENIORS 1ST
AL630477348034OtherTRICARE
AL7722482OtherAETNA
AL51507974Medicare PIN