MEDICARE: ELLIE MARIE FAXON PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1740078179
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLIE MARIE FAXON PA

Provider Business Mailing Address
First Line	:	343 S FARM ROAD 97
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65802-9270
Country	:	US
Telephone Number	:	970-818-6938
Fax Number	:

Provider Business Practice Location Address
First Line	:	1499 N ROBBERSON AVE STE K500
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65802-1979
Country	:	US
Telephone Number	:	417-269-2667
Fax Number	:	417-269-2668

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/26/2025
Last Update Date	:	08/05/2025

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Directions to “ ELLIE MARIE FAXON PA” Practice Location

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