Provider Demographics
NPI:1851454318
Name:KRAG, ELLEN (PA)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:KRAG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 ORNAC
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-4159
Mailing Address - Country:US
Mailing Address - Phone:978-287-3167
Mailing Address - Fax:978-287-3391
Practice Address - Street 1:133 ORNAC
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-4159
Practice Address - Country:US
Practice Address - Phone:978-287-3167
Practice Address - Fax:978-287-3391
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA458363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS68899Medicare UPIN