Provider Demographics
NPI:1962634246
Name:ELLSWORTH, CORWIN RYAN (PA-C)
Entity Type:Individual
Prefix:
First Name:CORWIN
Middle Name:RYAN
Last Name:ELLSWORTH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:C
Other - Middle Name:RYAN
Other - Last Name:ELLSWORTH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 3610
Mailing Address - Street 2:
Mailing Address - City:PINETOP
Mailing Address - State:AZ
Mailing Address - Zip Code:85935-3610
Mailing Address - Country:US
Mailing Address - Phone:928-367-3926
Mailing Address - Fax:928-367-4916
Practice Address - Street 1:728 E WHITE MOUNTAIN BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:PINETOP
Practice Address - State:AZ
Practice Address - Zip Code:85935
Practice Address - Country:US
Practice Address - Phone:928-367-3926
Practice Address - Fax:928-367-4916
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-20
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2609363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ779548Medicaid