Provider Demographics
NPI:1144693284
Name:DORNSEIF, ELLYN GABRIELLE (PA-C)
Entity type:Individual
Prefix:
First Name:ELLYN
Middle Name:GABRIELLE
Last Name:DORNSEIF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELLYN
Other - Middle Name:GABRIELLE
Other - Last Name:YACKANICZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:701 OSTRUM ST
Mailing Address - Street 2:SUITE 603
Mailing Address - City:FOUNTAIN HILL
Mailing Address - State:PA
Mailing Address - Zip Code:18015-1155
Mailing Address - Country:US
Mailing Address - Phone:484-526-3990
Mailing Address - Fax:610-868-2915
Practice Address - Street 1:701 OSTRUM ST
Practice Address - Street 2:SUITE 603
Practice Address - City:FOUNTAIN HILL
Practice Address - State:PA
Practice Address - Zip Code:18015-1155
Practice Address - Country:US
Practice Address - Phone:484-526-3990
Practice Address - Fax:610-868-2915
Is Sole Proprietor?:No
Enumeration Date:2015-11-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA057837363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA71812OtherMEDICARE
PA1007307530136Medicaid
PA1007307530136Medicaid