Provider Demographics
NPI:1699754002
Name:FORTIER, ELLEN R (PA)
Entity type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:R
Last Name:FORTIER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3212 W FIELDER ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33611-2912
Mailing Address - Country:US
Mailing Address - Phone:813-966-1699
Mailing Address - Fax:
Practice Address - Street 1:2191 9TH AVE N
Practice Address - Street 2:SUITE 240
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-7146
Practice Address - Country:US
Practice Address - Phone:727-821-7163
Practice Address - Fax:727-822-6017
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 0003227363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE7100BMedicare ID - Type Unspecified