Provider Demographics
NPI:1518580646
Name:ELLIS, CARISSA (DMSC, PA-C)
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:
Credentials:DMSC, 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:PO BOX 6149
Mailing Address - Street 2:
Mailing Address - City:ALOHA
Mailing Address - State:OR
Mailing Address - Zip Code:97007-0149
Mailing Address - Country:US
Mailing Address - Phone:503-352-6000
Mailing Address - Fax:
Practice Address - Street 1:2725 SW CEDAR HILLS BLVD STE 200
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-1435
Practice Address - Country:US
Practice Address - Phone:503-352-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-22
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program