Provider Demographics
NPI:1619944709
Name:ELLIS, DAVID (CRNA)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 E. HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHELAN
Mailing Address - State:WA
Mailing Address - Zip Code:98816
Mailing Address - Country:US
Mailing Address - Phone:509-682-8517
Mailing Address - Fax:509-682-6131
Practice Address - Street 1:503 E HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:CHELAN
Practice Address - State:WA
Practice Address - Zip Code:98816-8631
Practice Address - Country:US
Practice Address - Phone:509-682-8517
Practice Address - Fax:509-682-6131
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30005489367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9631276Medicaid
WA9631276Medicaid