Provider Demographics
NPI:1518100403
Name:ELLWOOD, REBECCA (PA-C)
Entity type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:
Last Name:ELLWOOD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1365 WASHINGTON AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12206-1098
Mailing Address - Country:US
Mailing Address - Phone:518-489-4704
Mailing Address - Fax:518-810-0043
Practice Address - Street 1:1365 WASHINGTON AVE STE 300
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12206-1098
Practice Address - Country:US
Practice Address - Phone:518-489-4704
Practice Address - Fax:518-810-0043
Is Sole Proprietor?:No
Enumeration Date:2009-04-08
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013029363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical