Provider Demographics
NPI:1669469128
Name:ELLIS, JOHN W (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:W
Last Name:ELLIS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
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Mailing Address - Street 1:525 WESTERN AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-4967
Mailing Address - Country:US
Mailing Address - Phone:501-327-6665
Mailing Address - Fax:501-730-0289
Practice Address - Street 1:525 WESTERN AVE
Practice Address - Street 2:STE 201
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-4967
Practice Address - Country:US
Practice Address - Phone:501-327-6665
Practice Address - Fax:501-730-0289
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-30
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ARC01093207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
5T850Medicare ID - Type Unspecified