Provider Demographics
NPI:1447513239
Name:ELLINGSEN, CHRISTOPHER R (PA-C)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:R
Last Name:ELLINGSEN
Suffix:
Gender:M
Credentials:PA-C
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:PEDIATRIC EMERGENCY MEDICINE
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-2625
Mailing Address - Fax:414-266-2635
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:PEDIATRIC EMERGENCY MEDICINE
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-2625
Practice Address - Fax:414-266-2635
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI2949363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1447513239Medicaid