Provider Demographics
NPI:1679767636
Name:ELLIS, NORA DENISE (PAC)
Entity Type:Individual
Prefix:
First Name:NORA
Middle Name:DENISE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21001 N TATUM BLVD
Mailing Address - Street 2:STE 1630-156
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-4206
Mailing Address - Country:US
Mailing Address - Phone:623-215-9951
Mailing Address - Fax:
Practice Address - Street 1:34406 N 27TH DR
Practice Address - Street 2:BLDG 6, STE 100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085-6082
Practice Address - Country:US
Practice Address - Phone:623-215-9951
Practice Address - Fax:480-350-7540
Is Sole Proprietor?:No
Enumeration Date:2007-09-04
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3675363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ170156OtherMEDICARE PTAN