Provider Demographics
NPI:1932119435
Name:ELLIS, DALE EDWIN
Entity Type:Individual
Prefix:MR
First Name:DALE
Middle Name:EDWIN
Last Name:ELLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 SHADY REST ROAD
Mailing Address - Street 2:
Mailing Address - City:MORGANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28655
Mailing Address - Country:US
Mailing Address - Phone:828-439-8506
Mailing Address - Fax:
Practice Address - Street 1:1000 S STERLING ST
Practice Address - Street 2:
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655
Practice Address - Country:US
Practice Address - Phone:828-433-2235
Practice Address - Fax:828-433-2491
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100890363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant