Healthcare Provider Details

I. General information

NPI: 1063140820
Provider Name (Legal Business Name): MATTHEW RYAN ELLIS RN, AG-ACNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2022
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 S COULTER ST
AMARILLO TX
79106-1786
US

IV. Provider business mailing address

2223 S HUGHES ST
AMARILLO TX
79109-2213
US

V. Phone/Fax

Practice location:
  • Phone: 806-414-9558
  • Fax:
Mailing address:
  • Phone: 806-702-0777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number1089531
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: