Basic Information
| Provider Information | |||||||||
| NPI: | 1609103738 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLENDER | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | IV | ||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 325 WESTERN BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285466341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9105771555 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2716 ASHTON DR | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284122489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103323800 | ||||||||
| FaxNumber: | 9102510421 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2009 | ||||||||
| LastUpdateDate: | 02/20/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.