MEDICARE: NORA DENISE ELLIS PAC

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	363AM0700X	Medical Physician Assistant	3675	AZ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Z170156	OTHER	AZ	MEDICARE PTAN

General Provider Information

NPI Number	:	1679767636
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NORA DENISE ELLIS PAC

Provider Business Mailing Address
First Line	:	21001 N TATUM BLVD
Second Line	:	STE 1630-156
City	:	PHOENIX
State	:	AZ
Zip	:	85050-4206
Country	:	US
Telephone Number	:	623-215-9951
Fax Number	:

Provider Business Practice Location Address
First Line	:	34406 N 27TH DR
Second Line	:	BLDG 6, STE 100
City	:	PHOENIX
State	:	AZ
Zip	:	85085-6082
Country	:	US
Telephone Number	:	623-215-9951
Fax Number	:	480-350-7540

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

Provider Enumeration Date	:	09/04/2007
Last Update Date	:	11/03/2014

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Directions to “ NORA DENISE ELLIS PAC” Practice Location

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