Basic Information
| Provider Information | |||||||||
| NPI: | 1770076051 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ERVIN, PA | ||||||||
| FirstName: | ALEXANDRIA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 19453 VISTA AVE | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730123528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9189550834 | ||||||||
| FaxNumber: | 4057491671 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 S MUSTANG RD | ||||||||
| Address2: | |||||||||
| City: | YUKON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730996704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053241911 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2018 | ||||||||
| LastUpdateDate: | 01/16/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2940 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.