Provider Demographics
NPI:1184840597
Name:ELLIS, G RICHARD (PA-C)
Entity Type:Individual
Prefix:
First Name:G
Middle Name:RICHARD
Last Name:ELLIS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 MEDICAL DR
Mailing Address - Street 2:SUITE #310
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-4968
Mailing Address - Country:US
Mailing Address - Phone:801-397-3000
Mailing Address - Fax:801-397-0455
Practice Address - Street 1:520 MEDICAL DR
Practice Address - Street 2:SUITE #310
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4968
Practice Address - Country:US
Practice Address - Phone:801-397-3000
Practice Address - Fax:801-397-0455
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT265444-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1477643179OtherGROUP NPI
UT1477643179OtherGROUP NPI
UT005516404Medicare PIN