Basic Information
| Provider Information | |||||||||
| NPI: | 1720663057 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | CHESTON | ||||||||
| MiddleName: | PAUL | ||||||||
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| Credential: | APRN-CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3216 WEXFORD AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731791202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053970150 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3300 NW EXPRESSWAY | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731124999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059493011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2021 | ||||||||
| LastUpdateDate: | 03/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | 201176 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.