Provider Demographics
NPI:1740879394
Name:ELLIS, KILLIAN (PA-C)
Entity type:Individual
Prefix:
First Name:KILLIAN
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:16 SUGAR MAPLE LN
Mailing Address - Street 2:
Mailing Address - City:ONA
Mailing Address - State:WV
Mailing Address - Zip Code:25545-3500
Mailing Address - Country:US
Mailing Address - Phone:304-360-5498
Mailing Address - Fax:
Practice Address - Street 1:4500 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1806
Practice Address - Country:US
Practice Address - Phone:304-926-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant