Provider Demographics
NPI:1891199972
Name:ELLIS, TADECHER (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:TADECHER
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
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 1:2724 SW 84TH TER
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-2962
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2724 SW 84TH TER
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33025-2962
Practice Address - Country:US
Practice Address - Phone:203-360-6824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-17
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108390363AM0700X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical