Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204C00000X | Sports Medicine Doctor | 024782 | LA |
Y | 2081P2900X | Pain Medicine | 024782 | LA |
NPI | 1174688857 |
---|---|
Provider Name | Dr. Walter Wright Ellis |
First Address | Saint Rose, LA 70087-3765 |
Second Address | Metairie, LA 70002-2046 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/12/2006 |
Last Update Date | 10/10/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1489417 | (05) | LA |
H82844 | (02) | LA |