Provider Demographics
NPI:1104584390
Name:LOCKWOOD, ELLEN NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:NICOLE
Last Name:LOCKWOOD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:38135 MARKET SQ
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33542-7505
Mailing Address - Country:US
Mailing Address - Phone:352-567-0188
Mailing Address - Fax:813-355-5101
Practice Address - Street 1:3820 NORTHDALE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624-1863
Practice Address - Country:US
Practice Address - Phone:813-712-5702
Practice Address - Fax:813-377-1005
Is Sole Proprietor?:No
Enumeration Date:2021-12-04
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
363A00000X
FLPA9115565363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant