Provider Demographics
NPI:1568483006
Name:ELLIS, MARTHA A (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:A
Last Name:ELLIS
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 1:13840 N NORTHSIGHT BLVD STE 121
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-3665
Mailing Address - Country:US
Mailing Address - Phone:480-588-6924
Mailing Address - Fax:480-634-5819
Practice Address - Street 1:13840 N NORTHSIGHT BLVD STE 121
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260
Practice Address - Country:US
Practice Address - Phone:480-588-6924
Practice Address - Fax:480-634-5819
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004629363A00000X
AZ2486363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZQ10979Medicare UPIN