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Individual
JAY T ELLIS
Active
Individual
JAY T ELLIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PT, DPT, CSCS
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
Primary
RPT231
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
316942
BLUE SHIELD
ID
05
—
804274500
—
ID
01
—
T0742
BLUE CROSS OF IDAHO
ID
Enumeration date
06/26/2006
Last updated
03/04/2011
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