Provider Demographics
NPI:1013274620
Name:ELLSWORTH, ELIZA CAGUIOA (DPT)
Entity Type:Individual
Prefix:DR
First Name:ELIZA
Middle Name:CAGUIOA
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:ELIZA
Other - Middle Name:NICOLAS
Other - Last Name:CAGUIOA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3427
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:AK
Mailing Address - Zip Code:99559-3427
Mailing Address - Country:US
Mailing Address - Phone:907-543-6452
Mailing Address - Fax:
Practice Address - Street 1:700 CHIEF EDDIE HOFFMAN HWY
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:AK
Practice Address - Zip Code:99559
Practice Address - Country:US
Practice Address - Phone:907-543-6342
Practice Address - Fax:907-543-6580
Is Sole Proprietor?:No
Enumeration Date:2012-04-19
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK103069225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200436060AMedicaid
OK200436060AMedicaid