Provider Demographics
NPI:1629017850
Name:ELLIS, KATIE JO (PA)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:JO
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 E LIMA ST
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:OH
Mailing Address - Zip Code:45843-1118
Mailing Address - Country:US
Mailing Address - Phone:419-273-2553
Mailing Address - Fax:419-273-3337
Practice Address - Street 1:730 W MARKET ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-4602
Practice Address - Country:US
Practice Address - Phone:419-227-3361
Practice Address - Fax:419-226-9826
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001778363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00126759OtherMEDICARE RR
OHP00126759OtherMEDICARE RR
P57432Medicare UPIN