Provider Demographics
NPI:1932283397
Name:ELLIS, SARA JANE (PT)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:JANE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 6TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1901
Mailing Address - Country:US
Mailing Address - Phone:320-229-4922
Mailing Address - Fax:320-229-5183
Practice Address - Street 1:1406 6TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303
Practice Address - Country:US
Practice Address - Phone:320-229-4922
Practice Address - Fax:320-229-5183
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6210225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP30970OtherHEALTHPARTNERS
MNP00024072OtherRAILROAD MEDICARE
MN088475800Medicaid
MN382S9ELOtherBLUE CROSS BLUE SHIELD
MN64-03510OtherMEDICA AND SELECT CARE