Provider Demographics
NPI:1750301289
Name:ELLIS, RANDI M (PAC)
Entity Type:Individual
Prefix:
First Name:RANDI
Middle Name:M
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 1:2820 CENTRAL AVE
Mailing Address - Street 2:STE A
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59102-8624
Mailing Address - Country:US
Mailing Address - Phone:406-252-8346
Mailing Address - Fax:
Practice Address - Street 1:2820 CENTRAL AVE STE A
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59102
Practice Address - Country:US
Practice Address - Phone:406-252-8346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT412363A00000X
MTMED-PAC-LIC-412363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY121397100OtherMDCD PIN
MT4305704OtherMDCD PIN
MT000096373OtherBCBS PIN
MTS87120Medicare UPIN
MT000096373OtherBCBS PIN
WY121397100OtherMDCD PIN
MT4305704OtherMDCD PIN
MT000084694Medicare PIN