Healthcare Provider Details

I. General information

NPI: 1649291196
Provider Name (Legal Business Name): ALLAN J. ELLSWORTH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 10/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1959 NE PACIFIC ST
SEATTLE WA
98195-0001
US

IV. Provider business mailing address

PO BOX 24366
SEATTLE WA
98124-0366
US

V. Phone/Fax

Practice location:
  • Phone: 206-598-5618
  • Fax: 206-598-5720
Mailing address:
  • Phone: 206-598-0502
  • Fax: 206-598-0516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA10004406
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: