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General NPI Number Information
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NPI Number | 1033196571
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Entity Type | Individual
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Provider Name | TINA R ELLISON PA-C
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Gender | Female
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Dates
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Enumeration Date | 12/27/2005
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Last Update Date | 09/17/2024
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Provider Practice Location Address
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Address Line | 61 MEMORIAL MEDICAL PKWY STE 1-800A
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City | PALM COAST
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State | FL
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Zip | 32164-5983
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Country | US
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Telephone | 386-302-1365
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 946383
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City | ATLANTA
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State | GA
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Zip | 30394-6383
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 50-001637
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA9117754
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License Number State | FL
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