Healthcare Provider Details

I. General information

NPI: 1114598042
Provider Name (Legal Business Name): ELISE NICOLE WELBOURNE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2021
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 W TECUMSEH RD STE 106
NORMAN OK
73072-1810
US

IV. Provider business mailing address

3400 W TECUMSEH RD STE 106
NORMAN OK
73072-1810
US

V. Phone/Fax

Practice location:
  • Phone: 405-314-0044
  • Fax: 405-307-5621
Mailing address:
  • Phone: 405-515-0044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4571
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: