Active NPI
Thomas Wilks Ellis III, P.A. C
- Physician Assistant
- Maple Grove, MN
National Provider Identifier
1881632891
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physician Assistant
- License
- 9063
- Practice address
- 12000 Elm Creek Blvd N
Suite 360
Maple Grove, MN 55369-7073 - Phone
- (763) 315-4300
- Fax
- (763) 315-4360
- NPI assigned
- Jun 2, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | 9063 | MN | Primary |
Addresses
Primary practice location
12000 Elm Creek Blvd N
Suite 360
Maple Grove, MN 55369-7073
Mailing address
2873 233Rd LN NW
St Francis, MN 55070-8630
Phone (763) 753-3306
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in CA
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: No
Enrollment records 1
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- HHS exclusion list flag
- CMS’s directory marks this NPI as on an HHS exclusion list; no matching OIG record was found.
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 9063 | MN | MD | Assistive Technology Supplier Audiologist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Allure Esthetics | Past | Accepting new patients |
Interoperability endpoints
- thomas.ellis.p9@direct.regal.nextgenshare.com
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Family Medicine Physician
- Bakersfield, CA
- NPI 1861698102
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1149206400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1348444800000",
"number": "1881632891",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2873 233RD LN NW",
"city": "ST FRANCIS",
"state": "MN",
"postal_code": "550708630",
"telephone_number": "763-753-3306"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "12000 ELM CREEK BLVD N",
"address_2": "SUITE 360",
"city": "MAPLE GROVE",
"state": "MN",
"postal_code": "553697073",
"telephone_number": "763-315-4300",
"fax_number": "763-315-4360"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ELLIS",
"first_name": "THOMAS",
"middle_name": "WILKS",
"name_suffix": "III",
"credential": "P.A. C",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-06-02",
"last_updated": "2012-09-24",
"status": "A"
},
"taxonomies": [
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "MN",
"license": "9063",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Maple Grove, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 24, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.