Healthcare Provider Details

I. General information

NPI: 1568483006
Provider Name (Legal Business Name): MARTHA A ELLIS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 01/10/2026
Certification Date: 01/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4455 E CAMELBACK RD STE D155
PHOENIX AZ
85018-2888
US

IV. Provider business mailing address

PO BOX 88747
MILWAUKEE WI
53288-8747
US

V. Phone/Fax

Practice location:
  • Phone: 480-626-2444
  • Fax: 888-473-4947
Mailing address:
  • Phone: 480-945-6777
  • Fax: 480-257-7310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2486
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10004629
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: