Individual
DENNARD W ELLISON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
106 BLANCA AVE, SAN LUIS VALLEY REGIONAL MEDICAL CENTER, ALAMOSA, CO 81101-2340
(719) 589-8025
(719) 589-8087
Mailing address
106 BLANCA AVE, SAN LUIS VALLEY REGIONAL MEDICAL CENTER, ALAMOSA, CO 81101-2340
(719) 589-8025
(719) 589-8087
Taxonomy
Speciality
Code
Description
License number
State
207Y00000X
Otolaryngology Physician
20020441
NM
207Y00000X
Otolaryngology Physician
Primary
48628
CO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00182257
—
CO
05
—
52787761
—
NM
01
—
COA100184
MEDICARE PTAN
CO
Enumeration date
10/03/2006
Last updated
05/05/2021
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