Provider Demographics
NPI:1417963109
Name:JANKOWSKI, ELLEN B (PA-C)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:B
Last Name:JANKOWSKI
Suffix:
Gender:F
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 1:100 GANNETT DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-5900
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:207-874-1483
Practice Address - Street 1:84 MARGINAL WAY
Practice Address - Street 2:SUITE 700
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101
Practice Address - Country:US
Practice Address - Phone:207-774-5816
Practice Address - Fax:207-523-8597
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2020-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004431363A00000X, 363AM0700X
MEPA001161363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0166563OtherL&I PIN
ME272170099Medicaid
WA8324659Medicaid
WA54807UOtherREGENCE BLUE SHIELD PIN
P82726Medicare UPIN
WA8324659Medicaid
WA0166563OtherL&I PIN
ME272170099Medicaid
WAAB35552Medicare PIN