Provider Demographics
NPI:1093748923
Name:ROSS, MICHAEL ALAN (PAC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALAN
Last Name:ROSS
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 WEGIS AVE
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93314-7878
Mailing Address - Country:US
Mailing Address - Phone:661-589-8891
Mailing Address - Fax:
Practice Address - Street 1:900 QUEBEC
Practice Address - Street 2:
Practice Address - City:CORCORAN
Practice Address - State:CA
Practice Address - Zip Code:93212
Practice Address - Country:US
Practice Address - Phone:559-992-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14386363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00281488Medicare ID - Type UnspecifiedRAILROAD MEDICARE
CAS72561Medicare UPIN