Provider Demographics
NPI:1114198702
Name:ROSS, MICHELLE LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:ROSS
Suffix:
Gender:F
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 1:219 W 17TH ST
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42240-1911
Mailing Address - Country:US
Mailing Address - Phone:270-886-5141
Mailing Address - Fax:
Practice Address - Street 1:1724 KENTON ST STE 1C
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-1981
Practice Address - Country:US
Practice Address - Phone:270-886-5141
Practice Address - Fax:270-885-1877
Is Sole Proprietor?:No
Enumeration Date:2008-03-21
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1584363A00000X
KYTC683363AM0700X
KYPA2332363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100523490Medicaid