Provider Demographics
NPI:1124009261
Name:ROSS, CARRI L (PA)
Entity Type:Individual
Prefix:
First Name:CARRI
Middle Name:L
Last Name:ROSS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CARRI
Other - Middle Name:L
Other - Last Name:MAYES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:4104 VESTAL RD.
Mailing Address - Street 2:VESTAL EXECUTIVE PARK SUITE 203
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850
Mailing Address - Country:US
Mailing Address - Phone:607-797-9036
Mailing Address - Fax:607-798-0601
Practice Address - Street 1:4104 VESTAL RD
Practice Address - Street 2:VESTAL EXECUTIVE PARK SUITE 203
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-3500
Practice Address - Country:US
Practice Address - Phone:607-797-9036
Practice Address - Fax:607-798-0601
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0095771363AM0700X
NY009577-1207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPA0082Medicare PIN
NY02571171Medicaid