Provider Demographics
NPI:1780037788
Name:ELLIS, STEPHANIE ANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANNE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 ARGYLE ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14607-2301
Mailing Address - Country:US
Mailing Address - Phone:518-653-7821
Mailing Address - Fax:
Practice Address - Street 1:789 PRE EMPTION RD
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456-2069
Practice Address - Country:US
Practice Address - Phone:315-789-5061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-14
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant