Provider Demographics
NPI:1225420334
Name:ELLENBERG, EVAN (PA-C)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:ELLENBERG
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 1:12111 PANAMA CITY BEACH PKWY
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32407-2609
Mailing Address - Country:US
Mailing Address - Phone:850-588-1036
Mailing Address - Fax:850-588-1036
Practice Address - Street 1:12111 PANAMA CITY BEACH PKWY
Practice Address - Street 2:
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32407-2609
Practice Address - Country:US
Practice Address - Phone:850-588-1066
Practice Address - Fax:850-588-1036
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-26
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108571207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1225420334OtherINSURANCE