Provider Demographics
NPI:1639215031
Name:ELLIS, BRADLEY WADE
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:WADE
Last Name:ELLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19293 NW 230TH ST
Mailing Address - Street 2:
Mailing Address - City:HIGH SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32643
Mailing Address - Country:US
Mailing Address - Phone:352-328-6427
Mailing Address - Fax:
Practice Address - Street 1:4820 NEWBERRY ROAD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607
Practice Address - Country:US
Practice Address - Phone:352-373-2116
Practice Address - Fax:352-373-1507
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA19813225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
106774Medicare ID - Type Unspecified