Provider Demographics
NPI:1801527288
Name:ELLIS, COURTNEY (PA-C)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:ELLIS
Suffix:
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 1:1202 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7307
Mailing Address - Country:US
Mailing Address - Phone:910-341-1540
Mailing Address - Fax:910-431-4048
Practice Address - Street 1:8064 MARKET ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28411-0013
Practice Address - Country:US
Practice Address - Phone:910-796-7767
Practice Address - Fax:910-686-7159
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-17
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9117081207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty