Provider Demographics
NPI:1114195013
Name:ELLIS, DAWN (PA)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 WAYMONT CT
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3485
Mailing Address - Country:US
Mailing Address - Phone:407-323-3550
Mailing Address - Fax:407-330-5962
Practice Address - Street 1:410 WAYMONT CT
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3485
Practice Address - Country:US
Practice Address - Phone:407-323-3550
Practice Address - Fax:407-330-5962
Is Sole Proprietor?:No
Enumeration Date:2008-02-13
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2026363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant