Provider Demographics
NPI:1912723305
Name:ELLIS, LIAM TY (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:LIAM
Middle Name:TY
Last Name:ELLIS
Suffix:
Gender:
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10213 COOL WATERLILY AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-4380
Mailing Address - Country:US
Mailing Address - Phone:607-742-6390
Mailing Address - Fax:
Practice Address - Street 1:1 TAMPA GENERAL CIR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3571
Practice Address - Country:US
Practice Address - Phone:813-844-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-02
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11037436363LC0200X
FLAPRN11037436363L00000X
FLRN9522986163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine