Healthcare Provider Details

I. General information

NPI: 1336973106
Provider Name (Legal Business Name): ASHLEY BROOKE DYSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2024
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2406 BELL AVE
ELK CITY OK
73644-2262
US

IV. Provider business mailing address

2406 BELL AVE
ELK CITY OK
73644-2262
US

V. Phone/Fax

Practice location:
  • Phone: 580-303-7944
  • Fax:
Mailing address:
  • Phone: 580-303-7944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5314
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: