Provider Demographics
NPI:1023536364
Name:ELLIS-STOCKLEY, SAMUEL CHRISTOPHER (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:CHRISTOPHER
Last Name:ELLIS-STOCKLEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:30986 STONE RIDGE DR APT 14201
Mailing Address - Street 2:
Mailing Address - City:WIXOM
Mailing Address - State:MI
Mailing Address - Zip Code:48393-3891
Mailing Address - Country:US
Mailing Address - Phone:734-308-4260
Mailing Address - Fax:
Practice Address - Street 1:28300 ORCHARD LAKE RD STE 200
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3704
Practice Address - Country:US
Practice Address - Phone:248-539-8630
Practice Address - Fax:248-539-9045
Is Sole Proprietor?:No
Enumeration Date:2017-09-07
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601008376363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant