Provider Demographics
NPI:1033454699
Name:ELLIS, JEFFREY CHRISTIAN (PA-C)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:CHRISTIAN
Last Name:ELLIS
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 1:2150 W REPUBLIC RD STE 112
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-6056
Mailing Address - Country:US
Mailing Address - Phone:417-986-1291
Mailing Address - Fax:
Practice Address - Street 1:2150 W REPUBLIC RD STE 112
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-6056
Practice Address - Country:US
Practice Address - Phone:417-986-1291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-07
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022006238363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant