Provider Demographics
NPI:1740391044
Name:ELLISON, WESLEY
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:
Last Name:ELLISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2036
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58502-2036
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3502 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-0761
Practice Address - Country:US
Practice Address - Phone:701-222-2480
Practice Address - Fax:701-222-4537
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND8189207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND17894OtherBLUE SHIELD
ND11227Medicaid
NDCO4118OtherRR MEDICARE
ND11227Medicaid
NDN17894Medicare PIN