Provider Demographics
NPI:1730284019
Name:RUSHTON-ELLIS, DEBRA (PAC)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:RUSHTON-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 1:830 OAK ST
Mailing Address - Street 2:SUITE 105W
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-1168
Mailing Address - Country:US
Mailing Address - Phone:508-427-3668
Mailing Address - Fax:508-427-2610
Practice Address - Street 1:235 N PEARL ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1794
Practice Address - Country:US
Practice Address - Phone:781-337-4224
Practice Address - Fax:781-335-0429
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA957363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MARUAP1343Medicare ID - Type Unspecified