Provider Demographics
NPI:1366026361
Name:ELLIS, CHRISTOPHER DOMINICK (CRNP)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:DOMINICK
Last Name:ELLIS
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 LANTERN HILL RD
Mailing Address - Street 2:
Mailing Address - City:SHAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18708-9590
Mailing Address - Country:US
Mailing Address - Phone:570-606-7972
Mailing Address - Fax:
Practice Address - Street 1:667 N RIVER ST #201
Practice Address - Street 2:
Practice Address - City:PLAINS
Practice Address - State:PA
Practice Address - Zip Code:18705-1870
Practice Address - Country:US
Practice Address - Phone:570-823-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-06
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP023586363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily