Provider Demographics
NPI:1699402693
Name:ELLIS, TEYLOR N (PA-C)
Entity type:Individual
Prefix:
First Name:TEYLOR
Middle Name:N
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 1:401 N SENATE AVE UNIT 419
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46204-1286
Mailing Address - Country:US
Mailing Address - Phone:317-752-8191
Mailing Address - Fax:
Practice Address - Street 1:5718 CRAWFORDSVILLE RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46224-3704
Practice Address - Country:US
Practice Address - Phone:317-240-5001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-01
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
IN99114632A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant