Provider Demographics
NPI:1235345075
Name:ELLIS, BENJAMIN KWEKU (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:KWEKU
Last Name:ELLIS
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6206 ARBOR BANKS TER
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-7752
Mailing Address - Country:US
Mailing Address - Phone:804-796-5018
Mailing Address - Fax:
Practice Address - Street 1:901 CORRECTION WAY
Practice Address - Street 2:
Practice Address - City:JARRATT
Practice Address - State:VA
Practice Address - Zip Code:23870-9998
Practice Address - Country:US
Practice Address - Phone:434-535-7098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001469363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant