Provider Demographics
NPI:1972566651
Name:ELLIS, JUSTIN D (PA)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:D
Last Name:ELLIS
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Gender:M
Credentials:PA
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Mailing Address - Street 1:415 N CENTER ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28601-5057
Mailing Address - Country:US
Mailing Address - Phone:828-328-3300
Mailing Address - Fax:828-328-9101
Practice Address - Street 1:1771 TATE BLVD SE
Practice Address - Street 2:SUITE 201
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-4249
Practice Address - Country:US
Practice Address - Phone:828-324-4804
Practice Address - Fax:828-324-7256
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2015-06-03
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Provider Licenses
StateLicense IDTaxonomies
NC102909363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2752793Medicare PIN
NCP06135Medicare UPIN