Provider Demographics
NPI:1639717697
Name:CHINNASWAMY, ELLYSSA BRADY (PA-C)
Entity Type:Individual
Prefix:
First Name:ELLYSSA
Middle Name:BRADY
Last Name:CHINNASWAMY
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 1:749 EAGLE POINT DR
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-5000
Mailing Address - Country:US
Mailing Address - Phone:508-954-0741
Mailing Address - Fax:
Practice Address - Street 1:4940 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-2735
Practice Address - Country:US
Practice Address - Phone:508-954-0741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-20
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDCOOO7434363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant