Provider Demographics
NPI:1336392224
Name:ELLIS, ROBERT (SA-C)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8008 BLUE HOLE CT
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75070-4896
Mailing Address - Country:US
Mailing Address - Phone:214-227-2457
Mailing Address - Fax:214-764-0880
Practice Address - Street 1:8008 BLUE HOLE CT
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75070-4896
Practice Address - Country:US
Practice Address - Phone:214-227-2457
Practice Address - Fax:214-764-0880
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-23
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX07-131246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Single Specialty