Provider Demographics
NPI:1013733575
Name:ELLIS, STEPHEN THOMAS
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:THOMAS
Last Name:ELLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HOLLY PARK CT APT 6308
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30115-0226
Mailing Address - Country:US
Mailing Address - Phone:770-380-2334
Mailing Address - Fax:
Practice Address - Street 1:100 HOLLY PARK CT APT 6308
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30115-0226
Practice Address - Country:US
Practice Address - Phone:770-380-2334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant