Provider Demographics
NPI:1881629657
Name:ELLIS, SCOTT C (PA)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:C
Last Name:ELLIS
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 1:789 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03820-2526
Mailing Address - Country:US
Mailing Address - Phone:603-740-2163
Mailing Address - Fax:
Practice Address - Street 1:789 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-2526
Practice Address - Country:US
Practice Address - Phone:603-740-2163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA-619363AM0700X
NH0315P363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME242440099Medicaid
NH30330768Medicaid
ME242440099Medicaid
NHAP118601Medicare PIN