Provider Demographics
NPI:1881632891
Name:ELLIS, THOMAS WILKS III (PA C)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:WILKS
Last Name:ELLIS
Suffix:III
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 1:2873 233RD LN NW
Mailing Address - Street 2:
Mailing Address - City:ST FRANCIS
Mailing Address - State:MN
Mailing Address - Zip Code:55070-8630
Mailing Address - Country:US
Mailing Address - Phone:763-753-3306
Mailing Address - Fax:
Practice Address - Street 1:12000 ELM CREEK BLVD N
Practice Address - Street 2:SUITE 360
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-7073
Practice Address - Country:US
Practice Address - Phone:763-315-4300
Practice Address - Fax:763-315-4360
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9063363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNR97982Medicare UPIN