Provider Demographics
NPI:1932784386
Name:ELLSWORTH, SKYLER
Entity Type:Individual
Prefix:
First Name:SKYLER
Middle Name:
Last Name:ELLSWORTH
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 1:2840 S MERIDIAN RD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7960
Mailing Address - Country:US
Mailing Address - Phone:208-593-6393
Mailing Address - Fax:208-593-6402
Practice Address - Street 1:2840 S MERIDIAN RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7960
Practice Address - Country:US
Practice Address - Phone:208-593-6393
Practice Address - Fax:208-593-6402
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-16
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IDPA-2207363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty