Provider Demographics
NPI:1922625326
Name:ELLINGSON, JORDIN LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:JORDIN
Middle Name:LEE
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 1:4109 E 99TH AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33617-4434
Mailing Address - Country:US
Mailing Address - Phone:706-499-0203
Mailing Address - Fax:
Practice Address - Street 1:3919 TAMPA RD
Practice Address - Street 2:
Practice Address - City:OLDSMAR
Practice Address - State:FL
Practice Address - Zip Code:34677-3114
Practice Address - Country:US
Practice Address - Phone:727-733-6111
Practice Address - Fax:727-733-6002
Is Sole Proprietor?:No
Enumeration Date:2020-07-01
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113176363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant