Healthcare Provider Details

I. General information

NPI: 1174609424
Provider Name (Legal Business Name): MARK RYAN ELLIOTT PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2006
Last Update Date: 07/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 W ILLINOIS AVE
MIDLAND TX
79701-6407
US

IV. Provider business mailing address

3321 NEELY AVE APT L1
MIDLAND TX
79707-5830
US

V. Phone/Fax

Practice location:
  • Phone: 432-685-1111
  • Fax:
Mailing address:
  • Phone: 432-689-8479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA05006
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: