Provider Demographics
NPI:1306312822
Name:ELLIOTT, MICHAEL CHAD (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CHAD
Last Name:ELLIOTT
Suffix:
Gender:M
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 1:5212 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:WAKE VILLAGE
Mailing Address - State:TX
Mailing Address - Zip Code:75501-5930
Mailing Address - Country:US
Mailing Address - Phone:903-831-6848
Mailing Address - Fax:903-223-7089
Practice Address - Street 1:5212 W 7TH ST
Practice Address - Street 2:
Practice Address - City:WAKE VILLAGE
Practice Address - State:TX
Practice Address - Zip Code:75501-5930
Practice Address - Country:US
Practice Address - Phone:903-831-6848
Practice Address - Fax:903-223-7089
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-23
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12400363AM0700X
TXTEMPORARY363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200859940AMedicaid
TXP02599432OtherRR MCR