Provider Demographics
NPI:1063829653
Name:ELLEDGE, STEPHEN (PA)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:ELLEDGE
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 WILFORD HALL LOOP FL 1
Mailing Address - Street 2:
Mailing Address - City:JBSA LACKLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78236-5638
Mailing Address - Country:US
Mailing Address - Phone:210-292-3473
Mailing Address - Fax:
Practice Address - Street 1:1100 WILFORD HALL LOOP FL 1
Practice Address - Street 2:
Practice Address - City:JBSA LACKLAND
Practice Address - State:TX
Practice Address - Zip Code:78236-5638
Practice Address - Country:US
Practice Address - Phone:210-292-3473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-16
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No171000000XOther Service ProvidersMilitary Health Care Provider
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant