Basic Information
| Provider Information | |||||||||
| NPI: | 1386089357 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | KATIE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 YORK ST | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542204630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206639008 | ||||||||
| FaxNumber: | 9206841439 | ||||||||
| Practice Location | |||||||||
| Address1: | 2644 NW 63RD ST | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731164902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052545565 | ||||||||
| FaxNumber: | 4052545569 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2013 | ||||||||
| LastUpdateDate: | 06/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2217 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.