Provider Demographics
NPI:1831412063
Name:ELLSWORTH, BRENT ANGEL (PA-C)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:ANGEL
Last Name:ELLSWORTH
Suffix:
Gender:M
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 1:2001 S WOODRUFF AVE STE 9
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6371
Mailing Address - Country:US
Mailing Address - Phone:208-419-3002
Mailing Address - Fax:208-656-5652
Practice Address - Street 1:2001 S WOODRUFF AVE STE 9
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6371
Practice Address - Country:US
Practice Address - Phone:208-419-3002
Practice Address - Fax:208-656-5652
Is Sole Proprietor?:No
Enumeration Date:2010-03-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-844363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant