Provider Demographics
NPI:1144228685
Name:ELLINGSON, DAVID J (PA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:ELLINGSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3120 WATERMAN WAY
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-5252
Mailing Address - Country:US
Mailing Address - Phone:352-343-1216
Mailing Address - Fax:352-343-1582
Practice Address - Street 1:3120 WATERMAN WAY
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-5252
Practice Address - Country:US
Practice Address - Phone:352-343-1216
Practice Address - Fax:352-343-1582
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102690363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291796300Medicaid
FL291796300Medicaid
FLU2074ZMedicare ID - Type UnspecifiedINDIV. MEDICARE NUMBER