Provider Demographics
NPI:1215784210
Name:ELLIS, MATTHEW RYAN
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:RYAN
Last Name:ELLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 299
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:CA
Mailing Address - Zip Code:90630-0299
Mailing Address - Country:US
Mailing Address - Phone:714-650-6704
Mailing Address - Fax:
Practice Address - Street 1:615 W CIVIC CENTER DR
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4006
Practice Address - Country:US
Practice Address - Phone:714-795-3444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-06
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-ITNBVL175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist