Provider Demographics
NPI:1316921992
Name:ELLINGTON, HENRY DUDLEY III (PAC)
Entity type:Individual
Prefix:MR
First Name:HENRY
Middle Name:DUDLEY
Last Name:ELLINGTON
Suffix:III
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 E THOMAS RD
Mailing Address - Street 2:SUITE A-104
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7646
Mailing Address - Country:US
Mailing Address - Phone:888-381-4858
Mailing Address - Fax:
Practice Address - Street 1:1701 E THOMAS RD
Practice Address - Street 2:SUITE A-104
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7646
Practice Address - Country:US
Practice Address - Phone:888-381-4858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5574363A00000X
HIAMD-132363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIH101588Medicare PIN