MEDICARE: CLAYTON L ELLISON 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	363A00000X	Physician Assistant	PA9113397	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PA221	OTHER	AR	LICENSE NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295956316
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLAYTON L ELLISON PA

Provider Business Mailing Address
First Line	:	4205 BELFORT RD STE 4015
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-3623
Country	:	US
Telephone Number	:	904-450-6063
Fax Number	:	904-450-6401

Provider Business Practice Location Address
First Line	:	13137 SORRENTO RD
Second Line	:
City	:	PENSACOLA
State	:	FL
Zip	:	32507-8777
Country	:	US
Telephone Number	:	850-416-0020
Fax Number	:	850-492-6340

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

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	02/26/2021

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Directions to “ CLAYTON L ELLISON PA” Practice Location

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