Provider Demographics
NPI:1245688928
Name:ELLISON, JUSTIN MICHAEL
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:MICHAEL
Last Name:ELLISON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 BRADBURY DR SE STE 116
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4310
Mailing Address - Country:US
Mailing Address - Phone:505-272-1476
Mailing Address - Fax:
Practice Address - Street 1:1949 GUNBARREL RD STE 206
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-7133
Practice Address - Country:US
Practice Address - Phone:423-495-4349
Practice Address - Fax:423-495-4934
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-02
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9344794163W00000X
TN196881163W00000X
TN31438163WR0006X, 363L00000X
WAN360677930363L00000X
NM60350363L00000X
SDCP003314363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant