Provider Demographics
NPI:1043471097
Name:ELLIS, KIMBERLY E (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:E
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:E
Other - Last Name:STEBEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:80 SEYMOUR STREET
Mailing Address - Street 2:HARTFORD HOSPITAL CARDIOLOGY DEPT
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06102-8000
Mailing Address - Country:US
Mailing Address - Phone:860-972-2975
Mailing Address - Fax:
Practice Address - Street 1:80 SEYMOUR STREET
Practice Address - Street 2:HARTFORD HOSPITAL CARDIOLOGY DEPT
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06102-8000
Practice Address - Country:US
Practice Address - Phone:860-972-2975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002127363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT003021276Medicaid
CT003021276Medicaid