Provider Demographics
NPI:1033196571
Name:ELLISON, TINA R (PA-C)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:R
Last Name:ELLISON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:R
Other - Last Name:HASROUNI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 946383
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30394-6383
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:61 MEMORIAL MEDICAL PKWY STE 1-800A
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-5983
Practice Address - Country:US
Practice Address - Phone:386-302-1365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-001637363A00000X
FLPA9117754363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000316099OtherANTHEM
OHP00079777OtherRAILROAD MEDICARE
OHP00079777OtherRAILROAD MEDICARE
P53849Medicare UPIN