Provider Demographics
NPI:1952870339
Name:PHEARMAN, ELLYN MARIE (PA)
Entity Type:Individual
Prefix:MS
First Name:ELLYN
Middle Name:MARIE
Last Name:PHEARMAN
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:85 S UNION BLVD APT 514
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80228-2289
Mailing Address - Country:US
Mailing Address - Phone:206-551-7626
Mailing Address - Fax:
Practice Address - Street 1:251 COUNTY ROAD 120
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-4872
Practice Address - Country:US
Practice Address - Phone:320-202-8949
Practice Address - Fax:320-257-1733
Is Sole Proprietor?:No
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN12813363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN12813OtherMINNESOTA PHYSICIAN ASSISTANT LICENSE
COPA.0005431OtherCOLORADO DEPARTMENT OF REGULATORY AGENCIES