Provider Demographics
NPI:1518580646
Name:ELLIS, CARISSA
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 SE 8TH AVE STE 536
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4218
Mailing Address - Country:US
Mailing Address - Phone:503-352-7299
Mailing Address - Fax:
Practice Address - Street 1:1401 N 10TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:STAYTON
Practice Address - State:OR
Practice Address - Zip Code:97383-1486
Practice Address - Country:US
Practice Address - Phone:503-769-6386
Practice Address - Fax:503-769-5647
Is Sole Proprietor?:No
Enumeration Date:2020-05-22
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program