Provider Demographics
NPI:1740311513
Name:ELLIS, EUGENE (CRNA)
Entity type:Individual
Prefix:MR
First Name:EUGENE
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1385 HOLLOWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94132-2664
Mailing Address - Country:US
Mailing Address - Phone:415-867-0177
Mailing Address - Fax:415-867-0177
Practice Address - Street 1:5801 NORTH CANYON RD
Practice Address - Street 2:SUITE 230
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-5440
Practice Address - Country:US
Practice Address - Phone:925-275-9910
Practice Address - Fax:925-275-9823
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3473367500000X
CANA3473367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN4261510Medicaid
CANA0034730OtherBLUE SHIELD OF CA
CANA0034730OtherBLUE SHIELD OF CA
CADS901ZMedicare PIN