Provider Demographics
NPI:1467609149
Name:ELLIS, VICTORIA NICOLE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:NICOLE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7400 LYNN AVE
Mailing Address - Street 2:
Mailing Address - City:HAMLIN
Mailing Address - State:WV
Mailing Address - Zip Code:25523-1138
Mailing Address - Country:US
Mailing Address - Phone:304-824-5806
Mailing Address - Fax:304-824-5804
Practice Address - Street 1:200 VANCE ST
Practice Address - Street 2:
Practice Address - City:CHAPMANVILLE
Practice Address - State:WV
Practice Address - Zip Code:25508-9422
Practice Address - Country:US
Practice Address - Phone:304-855-0425
Practice Address - Fax:304-855-0427
Is Sole Proprietor?:No
Enumeration Date:2008-08-25
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01166363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810020410Medicaid
WV2034872Medicare PIN
WV2034871Medicare PIN
WVPA23762Medicare Oscar/Certification
WV2034874Medicare PIN
WV2034873Medicare PIN