Provider Demographics
NPI:1952961633
Name:HUMBERSTON, ELLEN A (PA-C)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:A
Last Name:HUMBERSTON
Suffix:
Gender:F
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 1:2400 PINE RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-7803
Mailing Address - Country:US
Mailing Address - Phone:715-847-2022
Mailing Address - Fax:715-847-2775
Practice Address - Street 1:2400 PINE RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-7803
Practice Address - Country:US
Practice Address - Phone:715-842-3196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-16
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty