Provider Demographics
NPI:1255960381
Name:SELF, ELLEN (PA-C)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:SELF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 SIX FLAGS CIR
Mailing Address - Street 2:
Mailing Address - City:BUELLTON
Mailing Address - State:CA
Mailing Address - Zip Code:93427-9555
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5580 CALLE REAL
Practice Address - Street 2:
Practice Address - City:GOLETA
Practice Address - State:CA
Practice Address - Zip Code:93111-1646
Practice Address - Country:US
Practice Address - Phone:805-617-7878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-01
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant