Provider Demographics
NPI:1083738736
Name:MEDRANO, ELLEN N (PA)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:N
Last Name:MEDRANO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:N
Other - Last Name:DAGGETT-MEDRANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:180 CHURCH HILL RD STE 1
Mailing Address - Street 2:
Mailing Address - City:LEEDS
Mailing Address - State:ME
Mailing Address - Zip Code:04263-3418
Mailing Address - Country:US
Mailing Address - Phone:207-524-3501
Mailing Address - Fax:207-524-2093
Practice Address - Street 1:180 CHURCH HILL RD STE 1
Practice Address - Street 2:
Practice Address - City:LEEDS
Practice Address - State:ME
Practice Address - Zip Code:04263-3418
Practice Address - Country:US
Practice Address - Phone:207-524-3501
Practice Address - Fax:207-524-2093
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA428363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1083738736Medicaid