Healthcare Provider Details

I. General information

NPI: 1801387428
Provider Name (Legal Business Name): JAMES RYAN ELLIS PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2018
Last Update Date: 05/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 FLORA GENE AVE W STE D
WIGGINS MS
39577-5010
US

IV. Provider business mailing address

321 FLORA GENE AVE W STE D
WIGGINS MS
39577-5010
US

V. Phone/Fax

Practice location:
  • Phone: 601-523-1994
  • Fax: 601-523-1995
Mailing address:
  • Phone: 601-523-1994
  • Fax: 601-523-1995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA6404
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: