Provider Demographics
NPI:1508868530
Name:ELLIS, MARK D (NP)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:D
Last Name:ELLIS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-2111
Mailing Address - Fax:
Practice Address - Street 1:208 HALEY RD
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TX
Practice Address - Zip Code:78636-4617
Practice Address - Country:US
Practice Address - Phone:830-868-9500
Practice Address - Fax:830-868-4606
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX609633363LF0000X
TXAP108475363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N3533OtherBLUE CROSS BLUE SHIELD
TX8N3533OtherBLUE CROSS BLUE SHIELD
TXS69084Medicare UPIN