Provider Demographics
NPI:1649212523
Name:ELLIS, LAURA B (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:B
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:30 TOWN SQUARE BLVD
Mailing Address - Street 2:SUITE 218
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28803-5066
Mailing Address - Country:US
Mailing Address - Phone:828-684-1212
Mailing Address - Fax:828-684-1103
Practice Address - Street 1:30 TOWN SQUARE BLVD STE 218
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28803-5080
Practice Address - Country:US
Practice Address - Phone:828-684-1212
Practice Address - Fax:828-684-1103
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200301455208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2021674Medicare PIN
NCG63959Medicare UPIN