Provider Demographics
NPI:1831122803
Name:ELLISON, KENNETH ROBERT (PA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ROBERT
Last Name:ELLISON
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 1:1032 MAR WALT DR
Mailing Address - Street 2:SUITE 250
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6661
Mailing Address - Country:US
Mailing Address - Phone:850-863-3463
Mailing Address - Fax:850-315-6051
Practice Address - Street 1:1032 MAR WALT DR
Practice Address - Street 2:SUITE 250
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6661
Practice Address - Country:US
Practice Address - Phone:850-863-3463
Practice Address - Fax:850-315-6051
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9106823363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical