Basic Information
| Provider Information | |||||||||
| NPI: | 1972566651 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | D. | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 N CENTER ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | HICKORY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286015057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283283300 | ||||||||
| FaxNumber: | 8283289101 | ||||||||
| Practice Location | |||||||||
| Address1: | 1771 TATE BLVD SE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | HICKORY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286024249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283244804 | ||||||||
| FaxNumber: | 8283247256 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 06/03/2015 | ||||||||
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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 | 102909 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.