Provider Demographics
NPI:1801115886
Name:ELLIS, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 BLUEBERRY LN
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:NC
Mailing Address - Zip Code:28730-9760
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 TUNNEL RD
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28805-2043
Practice Address - Country:US
Practice Address - Phone:828-298-7911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-31
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC189652367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN2319Medicaid
SCQ452573365Medicare PIN