Basic Information
| Provider Information | |||||||||
| NPI: | 1750689865 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | LISA | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 79 GLENRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | GLENVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 123024528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009896446 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 79 GLENRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | GLENVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 123024528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009896446 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2011 | ||||||||
| LastUpdateDate: | 08/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 014613-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.