Provider Demographics
NPI:1760150981
Name:ELLIMUTTIL, SHAJI JOSEPH (PA)
Entity Type:Individual
Prefix:MR
First Name:SHAJI
Middle Name:JOSEPH
Last Name:ELLIMUTTIL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 KNIGHTSBRIDGE RD APT 5204
Mailing Address - Street 2:
Mailing Address - City:FARMERS BRANCH
Mailing Address - State:TX
Mailing Address - Zip Code:75234-1378
Mailing Address - Country:US
Mailing Address - Phone:972-977-9301
Mailing Address - Fax:
Practice Address - Street 1:1100 ALLIED DR
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5348
Practice Address - Country:US
Practice Address - Phone:972-977-9301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA14664363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant