Provider Demographics
NPI:1013709336
Name:ELLIS, BRANDON LEE (PA-S)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:LEE
Last Name:ELLIS
Suffix:
Gender:M
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 ELM GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3901
Mailing Address - Country:US
Mailing Address - Phone:850-450-0002
Mailing Address - Fax:
Practice Address - Street 1:1104 ELM GROVE AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3901
Practice Address - Country:US
Practice Address - Phone:850-450-0002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-21
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program