Provider Demographics
NPI:1184392086
Name:ELLIOTT, MEGAN NICOLE
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:NICOLE
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:NICOLE
Other - Last Name:MELLON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:800 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-6130
Mailing Address - Country:US
Mailing Address - Phone:215-662-3340
Mailing Address - Fax:215-349-5890
Practice Address - Street 1:800 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-6130
Practice Address - Country:US
Practice Address - Phone:215-316-5151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-03
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00656700363A00000X
PAMA062711363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant