Provider Demographics
NPI:1780278499
Name:ELLIS, ROBERT JR (PA-C)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:ELLIS
Suffix:JR
Gender:
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 1:965 RIDGE LAKE BLVD STE 315
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9401
Mailing Address - Country:US
Mailing Address - Phone:877-348-1281
Mailing Address - Fax:901-227-3206
Practice Address - Street 1:6025 WALNUT GROVE RD STE 301
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2123
Practice Address - Country:US
Practice Address - Phone:901-226-0456
Practice Address - Fax:901-226-0458
Is Sole Proprietor?:No
Enumeration Date:2021-02-23
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
MSPA00540363AS0400X
TN5490363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical