Provider Demographics
NPI:1235284886
Name:ROSS, PATRICIA LYNN (MPA)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:LYNN
Last Name:ROSS
Suffix:
Gender:F
Credentials:MPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 ORCHARD AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1736
Mailing Address - Country:US
Mailing Address - Phone:304-842-8819
Mailing Address - Fax:
Practice Address - Street 1:104 ORCHARD AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1736
Practice Address - Country:US
Practice Address - Phone:304-842-8819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV771363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVQ56010Medicare UPIN
WVROPA25891Medicare PIN