MEDICARE: WARREN L ELLISON M.D.

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	207Q00000X	Family Medicine Physician	23004	WA

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	:	1982718235
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WARREN L ELLISON M.D.

Provider Business Mailing Address
First Line	:	1221 HIGHLAND AVE
Second Line	:
City	:	CLARKSTON
State	:	WA
Zip	:	99403-2829
Country	:	US
Telephone Number	:	509-758-5511
Fax Number	:

Provider Business Practice Location Address
First Line	:	1207 EVERGREEN CT
Second Line	:
City	:	CLARKSTON
State	:	WA
Zip	:	99403-2843
Country	:	US
Telephone Number	:	509-758-0875
Fax Number	:

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

Provider Enumeration Date	:	08/17/2006
Last Update Date	:	01/08/2013

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