Basic Information
| Provider Information | |||||||||
| NPI: | 1831122803 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLISON | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1032 MAR WALT DR | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325476661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508633463 | ||||||||
| FaxNumber: | 8503156051 | ||||||||
| Practice Location | |||||||||
| Address1: | 1032 MAR WALT DR | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325476661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508633463 | ||||||||
| FaxNumber: | 8503156051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 01/14/2022 | ||||||||
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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 | 363AM0700X | 9106823 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.