MEDICARE: MRS. PATRICIA MARIE ELLIS PA-C

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	007859	GA

General Provider Information

NPI Number	:	1346237450
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. PATRICIA MARIE ELLIS PA-C

Provider Business Mailing Address
First Line	:	900 CIRCLE 75 PKWY SE
Second Line	:	STE 1700
City	:	ATLANTA
State	:	GA
Zip	:	30339-3087
Country	:	US
Telephone Number	:	919-497-8411
Fax Number	:

Provider Business Practice Location Address
First Line	:	1265 HIGHWAY 54 W
Second Line	:	SUITE 102
City	:	FAYETTEVILLE
State	:	GA
Zip	:	30214-4548
Country	:	US
Telephone Number	:	770-460-1900
Fax Number	:	770-719-1214

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

Provider Enumeration Date	:	10/04/2005
Last Update Date	:	06/03/2016

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