Provider Demographics
NPI:1790965184
Name:ELLIS, DAVID JAMES (PA-C)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JAMES
Last Name:ELLIS
Suffix:
Gender:M
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 1:289 IRELAND AVE
Mailing Address - Street 2:IRELAND ARMY COMMUNITY HOSPITAL
Mailing Address - City:FORT KNOX
Mailing Address - State:KY
Mailing Address - Zip Code:40121-5111
Mailing Address - Country:US
Mailing Address - Phone:502-624-9007
Mailing Address - Fax:502-624-0252
Practice Address - Street 1:289 IRELAND AVE
Practice Address - Street 2:IRELAND ARMY COMMUNITY HOSPITAL
Practice Address - City:FORT KNOX
Practice Address - State:KY
Practice Address - Zip Code:40121-5111
Practice Address - Country:US
Practice Address - Phone:502-624-9007
Practice Address - Fax:502-624-0252
Is Sole Proprietor?:No
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
1037546363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant