Provider Demographics
NPI:1033100391
Name:ELVIS, FELICIA C (PA)
Entity Type:Individual
Prefix:
First Name:FELICIA
Middle Name:C
Last Name:ELVIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:FELICIA
Other - Middle Name:C
Other - Last Name:HAWTHORNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2101 E JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE REGIONAL HQ - 4E, PEU
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:
Practice Address - Street 1:1221 MERCANTILE LN
Practice Address - Street 2:KAISER PERMANENTE LARGO MEDICAL CENTER
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-5374
Practice Address - Country:US
Practice Address - Phone:301-618-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA30070363A00000X
MDC02031363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P67061Medicare UPIN
010012W15Medicare ID - Type Unspecified