Provider Demographics
NPI:1902457385
Name:ELLIS, ABIGAIL P (PA-C)
Entity type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:P
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 1:1703 INNOVATION DR STE 4120
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17408-8815
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1703 INNOVATION DR STE 4120
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17408-8815
Practice Address - Country:US
Practice Address - Phone:717-849-5576
Practice Address - Fax:717-849-5596
Is Sole Proprietor?:No
Enumeration Date:2019-09-26
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA065545363A00000X
VA0110006891363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1902457385Medicaid
VA30016153700001Medicaid