Provider Demographics
NPI:1891995056
Name:ELLINGSON, KATY (PA-C)
Entity Type:Individual
Prefix:
First Name:KATY
Middle Name:
Last Name:ELLINGSON
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 1:611 VETERANS PKWY
Mailing Address - Street 2:
Mailing Address - City:WOODRUFF
Mailing Address - State:WI
Mailing Address - Zip Code:54568-9195
Mailing Address - Country:US
Mailing Address - Phone:715-358-8610
Mailing Address - Fax:
Practice Address - Street 1:611 VETERANS PKWY
Practice Address - Street 2:
Practice Address - City:WOODRUFF
Practice Address - State:WI
Practice Address - Zip Code:54568-9195
Practice Address - Country:US
Practice Address - Phone:715-358-8610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2190-23363A00000X
WINOT YET ISSUED363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
033005090OtherMEDICARE
WI41946400Medicaid