Provider Demographics
NPI:1831458744
Name:ELLSWORTH, CARISSA ANNETTE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:ANNETTE
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1022 28TH ST W
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-2925
Mailing Address - Country:US
Mailing Address - Phone:801-450-7525
Mailing Address - Fax:
Practice Address - Street 1:1600 W ANTELOPE DR
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-1142
Practice Address - Country:US
Practice Address - Phone:801-807-7177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-11
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC-0481363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical