Provider Demographics
NPI:1922403450
Name:ELLIS, CHARLES
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:CHARLES
Other - Middle Name:GABRIEL
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:1675 WOODBROOKE DR
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-8502
Mailing Address - Country:US
Mailing Address - Phone:410-749-4154
Mailing Address - Fax:410-860-9583
Practice Address - Street 1:1675 WOODBROOKE DR
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-8502
Practice Address - Country:US
Practice Address - Phone:410-749-4154
Practice Address - Fax:410-860-9583
Is Sole Proprietor?:No
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC05576363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant