Provider Demographics
NPI:1316310832
Name:FLYNN, ELISSA NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:ELISSA
Middle Name:NICOLE
Last Name:FLYNN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELISSA
Other - Middle Name:NICOLE
Other - Last Name:BEEBE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:60 MDG/SGCQ
Mailing Address - Street 2:101 BODIN CIR
Mailing Address - City:TRAVIS AFB
Mailing Address - State:CA
Mailing Address - Zip Code:94535-1800
Mailing Address - Country:US
Mailing Address - Phone:707-423-5397
Mailing Address - Fax:
Practice Address - Street 1:60 MDG/SGCQ
Practice Address - Street 2:101 BODIN CIR
Practice Address - City:TRAVIS AFB
Practice Address - State:CA
Practice Address - Zip Code:94535-1800
Practice Address - Country:US
Practice Address - Phone:707-423-5397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-05
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA61662363AS0400X
1316310832363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical