MEDICARE: TINA MARLENE ELLIS PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	2889	SC
2	363A00000X	Physician Assistant	2889	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053648436
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TINA MARLENE ELLIS PA

Provider Business Mailing Address
First Line	:	4969 CENTRE POINTE DR
Second Line	:	STE 100
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29418-6952
Country	:	US
Telephone Number	:	843-853-0250
Fax Number	:	843-606-8103

Provider Business Practice Location Address
First Line	:	4969 CENTRE POINTE DR
Second Line	:	STE 100
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29418-6952
Country	:	US
Telephone Number	:	843-853-0250
Fax Number	:	843-606-8103

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/05/2009
Last Update Date	:	01/27/2022

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Directions to “ TINA MARLENE ELLIS PA” Practice Location

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