Provider Demographics
NPI:1386749695
Name:ELLIS, LELAND CALVIN JR (PA-C)
Entity type:Individual
Prefix:MR
First Name:LELAND
Middle Name:CALVIN
Last Name:ELLIS
Suffix:JR
Gender:M
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 1:4076 MOBLEYS BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GRIMESLAND
Mailing Address - State:NC
Mailing Address - Zip Code:27837-8999
Mailing Address - Country:US
Mailing Address - Phone:252-752-5811
Mailing Address - Fax:
Practice Address - Street 1:324A BEACON DR
Practice Address - Street 2:
Practice Address - City:WINTERVILLE
Practice Address - State:NC
Practice Address - Zip Code:28590-7956
Practice Address - Country:US
Practice Address - Phone:252-551-5595
Practice Address - Fax:252-321-7762
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103962363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ23873Medicare UPIN