Provider Demographics
NPI:1609945179
Name:ELLIS, DEIRDRE WOOLSEY (PA)
Entity Type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:WOOLSEY
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DEIRDRE
Other - Middle Name:LYNNE
Other - Last Name:WOOLSEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:20905 PROFESSIONAL PLAZA
Mailing Address - Street 2:SUITE 330
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147
Mailing Address - Country:US
Mailing Address - Phone:703-726-0003
Mailing Address - Fax:703-726-6444
Practice Address - Street 1:1110 TAMIAMI TRL N
Practice Address - Street 2:
Practice Address - City:NOKOMIS
Practice Address - State:FL
Practice Address - Zip Code:34275-2158
Practice Address - Country:US
Practice Address - Phone:727-766-0000
Practice Address - Fax:941-200-3932
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002387363A00000X
FLPA9112912363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant