Provider Demographics
NPI:1487056842
Name:ELLIS, EMILY (PA)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:
Other - Last Name:PADGETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:813-821-8038
Mailing Address - Fax:813-974-4325
Practice Address - Street 1:5430 FREDERICKSBURG RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3539
Practice Address - Country:US
Practice Address - Phone:210-297-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-17
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND6061133VN1004X
TXPA14548363A00000X
FLPA9112117363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105187500Medicaid
FL5ILU8OtherBLUE CROSS BLUE SHIELD