Provider Demographics
NPI:1982718235
Name:ELLISON, WARREN L (MD)
Entity Type:Individual
Prefix:
First Name:WARREN
Middle Name:L
Last Name:ELLISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-2829
Mailing Address - Country:US
Mailing Address - Phone:509-758-5511
Mailing Address - Fax:
Practice Address - Street 1:1207 EVERGREEN CT
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-2843
Practice Address - Country:US
Practice Address - Phone:509-758-0875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA23004207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1007293Medicaid
WA000300431Medicare PIN
WA1007293Medicaid
080007848Medicare PIN
WA000300431Medicare ID - Type Unspecified