Provider Demographics
NPI:1477669430
Name:ELLIS, JOHN A (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:ELLIS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:RANDALL
Other - Last Name:ATKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:744 W MICHIGAN AVE
Mailing Address - Street 2:PO BOX 1123
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1909
Mailing Address - Country:US
Mailing Address - Phone:517-787-6440
Mailing Address - Fax:517-787-4146
Practice Address - Street 1:44405 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-5023
Practice Address - Country:US
Practice Address - Phone:248-858-3023
Practice Address - Fax:248-858-3022
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704JA230495367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered