Basic Information
| Provider Information | |||||||||
| NPI: | 1306312822 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIOTT | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | CHAD | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 SAINT MICHAEL DR STE 401 | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755035211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036147693 | ||||||||
| FaxNumber: | 9036145343 | ||||||||
| Practice Location | |||||||||
| Address1: | 2602 SAINT MICHAEL DR STE 302B | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037944196 | ||||||||
| FaxNumber: | 9036145190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2018 | ||||||||
| LastUpdateDate: | 05/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA12400 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | TEMPORARY | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 200859940A | 05 | OK | MEDICAID | P02599432 | 01 | TX | RR MCR | OTHER |