Provider Demographics
NPI:1104440585
Name:ELLIS, KRISTINA LOUISE (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:LOUISE
Last Name:ELLIS
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 1:4100 LAKE OTIS PKWY STE 320
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5231
Mailing Address - Country:US
Mailing Address - Phone:907-563-4810
Mailing Address - Fax:907-563-4811
Practice Address - Street 1:4100 LAKE OTIS PKWY STE 320
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5231
Practice Address - Country:US
Practice Address - Phone:907-563-4810
Practice Address - Fax:907-563-4811
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-02
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK204589363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty