Provider Demographics
NPI:1043395874
Name:ELLIS, MELANIE JANE (PA)
Entity Type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:JANE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:145 CLAPBOARD RUN
Mailing Address - Street 2:
Mailing Address - City:CIBOLO
Mailing Address - State:TX
Mailing Address - Zip Code:78108-4334
Mailing Address - Country:US
Mailing Address - Phone:210-563-9646
Mailing Address - Fax:
Practice Address - Street 1:359 MEDICAL GROUP
Practice Address - Street 2:221 THRID STREET WEST, BLDG 1040
Practice Address - City:JBSA-RANDOLPH
Practice Address - State:TX
Practice Address - Zip Code:78150
Practice Address - Country:US
Practice Address - Phone:210-652-8544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003433363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical