Provider Demographics
NPI:1497060396
Name:FORT, ELLIS FRANKLIN III (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ELLIS
Middle Name:FRANKLIN
Last Name:FORT
Suffix:III
Gender:M
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 1:502 PALMETTO ST
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-7325
Mailing Address - Country:US
Mailing Address - Phone:869-571-8543
Mailing Address - Fax:386-878-4967
Practice Address - Street 1:502 PALMETTO ST
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168
Practice Address - Country:US
Practice Address - Phone:386-957-1854
Practice Address - Fax:386-878-4967
Is Sole Proprietor?:No
Enumeration Date:2010-08-16
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105205363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant