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General NPI Number Information
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NPI Number | 1174074991
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Entity Type | Individual
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Provider Name | ELYSIA SMALL PA
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Gender | Female
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Dates
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Enumeration Date | 10/17/2016
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Last Update Date | 07/25/2024
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Provider Practice Location Address
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Address Line | 1501 S YALE ST BUILDING 2 SUITE 150
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City | FLAGSTAFF
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State | AZ
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Zip | 86001-7304
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Country | US
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Telephone | 928-527-4325
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Fax | 928-527-4327
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Provider Business Mailing Address
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Address Line | PO BOX 35380
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City | LAS VEGAS
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State | NV
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Zip | 89133-5380
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Country | US
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Telephone | 702-954-7761
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Fax | 928-527-4327
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 6563
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License Number State | AZ
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