Provider Demographics
NPI:1417628793
Name:ELLIS SHORT, ADRIAN
Entity Type:Individual
Prefix:
First Name:ADRIAN
Middle Name:
Last Name:ELLIS SHORT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2306
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77410-2306
Mailing Address - Country:US
Mailing Address - Phone:203-506-1529
Mailing Address - Fax:
Practice Address - Street 1:15402 HAZEN POINT DR
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77433-6186
Practice Address - Country:US
Practice Address - Phone:203-506-1529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-25
Last Update Date:2021-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX305776364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist