Provider Demographics
NPI:1801387428
Name:ELLIS, JAMES RYAN (PTA)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:RYAN
Last Name:ELLIS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 FLORA GENE AVE W STE D
Mailing Address - Street 2:
Mailing Address - City:WIGGINS
Mailing Address - State:MS
Mailing Address - Zip Code:39577-5010
Mailing Address - Country:US
Mailing Address - Phone:601-523-1994
Mailing Address - Fax:601-523-1995
Practice Address - Street 1:321 FLORA GENE AVE W STE D
Practice Address - Street 2:
Practice Address - City:WIGGINS
Practice Address - State:MS
Practice Address - Zip Code:39577-5010
Practice Address - Country:US
Practice Address - Phone:601-523-1994
Practice Address - Fax:601-523-1995
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA6404225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant