Healthcare Provider Details

I. General information

NPI: 1902457385
Provider Name (Legal Business Name): ABIGAIL P ELLIS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2019
Last Update Date: 02/25/2025
Certification Date: 02/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1703 INNOVATION DR STE 4120
YORK PA
17408-8815
US

IV. Provider business mailing address

1703 INNOVATION DR STE 4120
YORK PA
17408-8815
US

V. Phone/Fax

Practice location:
  • Phone: 717-849-5576
  • Fax: 717-849-5596
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA065545
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110006891
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: