Provider Demographics
NPI:1093779852
Name:ROSS, CONRAD JOSEPH (PA-C)
Entity Type:Individual
Prefix:
First Name:CONRAD
Middle Name:JOSEPH
Last Name:ROSS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4687 COUNTY ROAD 13
Mailing Address - Street 2:
Mailing Address - City:MOOSE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55767-8109
Mailing Address - Country:US
Mailing Address - Phone:218-485-4479
Mailing Address - Fax:218-786-3918
Practice Address - Street 1:400 E 3RD ST
Practice Address - Street 2:MAILDROP: 1S2W50
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-1951
Practice Address - Country:US
Practice Address - Phone:218-786-3985
Practice Address - Fax:218-786-3018
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9581363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41921600Medicaid
MN659411500Medicaid
WI41921600Medicaid
MN659411500Medicaid