Healthcare Provider Details

I. General information

NPI: 1063829653
Provider Name (Legal Business Name): STEPHEN ELLEDGE P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2014
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51ST MEDICAL GROUP, UNIT 2060
APO AP
96278-2060
US

IV. Provider business mailing address

51ST MEDICAL GROUP, UNIT 2060
APO AP
96278-2060
US

V. Phone/Fax

Practice location:
  • Phone: 315-784-6444
  • Fax:
Mailing address:
  • Phone: 315-784-6444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1118688
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: