Basic Information
| Provider Information | |||||||||
| NPI: | 1962634246 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLSWORTH | ||||||||
| FirstName: | CORWIN | ||||||||
| MiddleName: | RYAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ELLSWORTH | ||||||||
| OtherFirstName: | C | ||||||||
| OtherMiddleName: | RYAN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 3610 | ||||||||
| Address2: | |||||||||
| City: | PINETOP | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859353610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283673926 | ||||||||
| FaxNumber: | 9283674916 | ||||||||
| Practice Location | |||||||||
| Address1: | 728 E WHITE MOUNTAIN BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | PINETOP | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283673926 | ||||||||
| FaxNumber: | 9283674916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2009 | ||||||||
| LastUpdateDate: | 08/20/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2609 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 779548 | 05 | AZ | MEDICAID |