Provider Demographics
NPI:1932376936
Name:ELLISON, SANTINA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:SANTINA
Middle Name:MARIE
Last Name:ELLISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13960 W WAINWRIGHT DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1969
Mailing Address - Country:US
Mailing Address - Phone:208-384-9022
Mailing Address - Fax:208-388-1683
Practice Address - Street 1:190 E BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6241
Practice Address - Country:US
Practice Address - Phone:208-381-2238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-09
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT7410499-1205207PE0004X
IDM-11508207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services