Provider Demographics
NPI:1962508754
Name:ELLIS, LAURIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:
Last Name:ELLIS
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 1:2900 CORPORATE WAY
Mailing Address - Street 2:DOOR D
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-3925
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1750 E HALLANDALE BEACH BLVD
Practice Address - Street 2:
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-4611
Practice Address - Country:US
Practice Address - Phone:954-276-9700
Practice Address - Fax:954-276-9725
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0000980363AM0700X
FLPA9110434363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD926580505Medicaid
MD926580506Medicaid
MD926580505Medicaid
MD926580506Medicaid
MDCD8143Medicare PIN
MD257244ZCSVMedicare PIN