Provider Demographics
NPI:1942966155
Name:ELLIS, ASHLEY (MS, PA-C)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 CRESCENT COVE CT
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11783-3648
Mailing Address - Country:US
Mailing Address - Phone:516-477-0713
Mailing Address - Fax:
Practice Address - Street 1:48 CRESCENT COVE CT
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:NY
Practice Address - Zip Code:11783-3648
Practice Address - Country:US
Practice Address - Phone:516-477-0713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-11
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY027988363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program