MEDICARE: GINA IRENE ELLINGSON PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program	000993	IA

General Provider Information

NPI Number	:	1669442554
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GINA IRENE ELLINGSON PA-C

Provider Business Mailing Address
First Line	:	BUILDING 0221
Second Line	:
City	:	CEDAR FALLS
State	:	IA
Zip	:	50614-0221
Country	:	US
Telephone Number	:	319-273-2009
Fax Number	:	319-273-7030

Provider Business Practice Location Address
First Line	:	BUILDING 0221
Second Line	:
City	:	CEDAR FALLS
State	:	IA
Zip	:	50614-0221
Country	:	US
Telephone Number	:	319-273-2009
Fax Number	:	319-273-7030

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2006
Last Update Date	:	07/08/2007

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