Provider Demographics
NPI:1487908786
Name:ELLSWORTH, AMY L (PAC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 9TH AVE
Mailing Address - Street 2:M4-PFS
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-2756
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 9TH AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2756
Practice Address - Country:US
Practice Address - Phone:206-583-2299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-08
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1022363A00000X
WAPA61202127363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant