Provider Demographics
NPI:1497069694
Name:CALLISON, ELLA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:ELLA
Middle Name:MARIE
Last Name:CALLISON
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 1:1611 S BALTIMORE ST STE A
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-4519
Mailing Address - Country:US
Mailing Address - Phone:660-665-7575
Mailing Address - Fax:660-665-7576
Practice Address - Street 1:1611 S BALTIMORE ST STE A
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501
Practice Address - Country:US
Practice Address - Phone:660-665-7575
Practice Address - Fax:660-665-7576
Is Sole Proprietor?:No
Enumeration Date:2010-07-29
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.003797363A00000X
MO2012008168363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1497069694Medicaid