Provider Demographics
NPI:1396161139
Name:ELLIS, CAITLIN (PA-C)
Entity type:Individual
Prefix:
First Name:CAITLIN
Middle Name:
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 1:9100 E PANORAMA DR STE 250
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80112-7212
Mailing Address - Country:US
Mailing Address - Phone:720-666-4739
Mailing Address - Fax:
Practice Address - Street 1:9100 E PANORAMA DR STE 250
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80112-7212
Practice Address - Country:US
Practice Address - Phone:720-666-4739
Practice Address - Fax:833-449-4351
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-17
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0003937363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN10004412AOtherSTATE LICENSE NUMBER
COPA0003937OtherSTATE LICENSE NUMBER
CA64522OtherSTATE LICENSE NUMBER
MN14921OtherSTATE LICENSE NUMBER
AZ10432OtherSTATE LICENSE NUMBER