Provider Demographics
NPI:1528353604
Name:ELLIS, SOPHIA ELIZABETH (PA-C)
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:ELIZABETH
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SOPHIA
Other - Middle Name:ELIZABETH
Other - Last Name:ROLLINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:200 NE MOTHER JOSEPH PL STE 210
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-3295
Mailing Address - Country:US
Mailing Address - Phone:360-254-6161
Mailing Address - Fax:360-449-1146
Practice Address - Street 1:200 NE MOTHER JOSEPH PL STE 110
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664
Practice Address - Country:US
Practice Address - Phone:360-254-6161
Practice Address - Fax:360-449-1146
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1528353604Medicaid
WA8903125Medicare PIN