Provider Demographics
NPI:1699573576
Name:ELLIS, ASHLEY (PA-C)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:ELLIS
Suffix:
Gender:
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 1:2401 STATE AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-3942
Mailing Address - Country:US
Mailing Address - Phone:850-628-9177
Mailing Address - Fax:502-385-6561
Practice Address - Street 1:2401 STATE AVE STE 100
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-3942
Practice Address - Country:US
Practice Address - Phone:850-628-9177
Practice Address - Fax:502-385-6561
Is Sole Proprietor?:No
Enumeration Date:2025-03-05
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9119888363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant