Provider Demographics
NPI:1114598042
Name:WELBOURNE, ELISE NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:NICOLE
Last Name:WELBOURNE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 W TECUMSEH RD STE 106
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-1810
Mailing Address - Country:US
Mailing Address - Phone:405-515-0044
Mailing Address - Fax:
Practice Address - Street 1:3400 W TECUMSEH RD STE 106
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-1810
Practice Address - Country:US
Practice Address - Phone:405-314-0044
Practice Address - Fax:405-307-5621
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-01
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4571363A00000X
TXPA14741363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant