Provider Demographics
NPI:1508480542
Name:KINGDOM, ELLEN (PA-C)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:KINGDOM
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 1:2301 HOUSE AVE STE 502
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3179
Mailing Address - Country:US
Mailing Address - Phone:307-635-4131
Mailing Address - Fax:
Practice Address - Street 1:2301 HOUSE AVE STE 502
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3179
Practice Address - Country:US
Practice Address - Phone:307-635-4131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-05
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0006279363A00000X
WYPT909363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant