Provider Demographics
NPI:1538219704
Name:ELLIS, WAYNE ENOCH (PHD, CRNA)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:ENOCH
Last Name:ELLIS
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Gender:M
Credentials:PHD, CRNA
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Other - First Name:
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Mailing Address - Street 1:1038 N EISENHOWER DR
Mailing Address - Street 2:SUITE 152
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-3116
Mailing Address - Country:US
Mailing Address - Phone:304-731-0102
Mailing Address - Fax:270-342-0001
Practice Address - Street 1:1038 N EISENHOWER DR
Practice Address - Street 2:SUITE 152
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3116
Practice Address - Country:US
Practice Address - Phone:304-731-0102
Practice Address - Fax:270-342-0001
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV65453367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered