Provider Demographics
NPI:1255329900
Name:ROSS, DOUGLAS JAY (PAC)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:JAY
Last Name:ROSS
Suffix:
Gender:M
Credentials:PAC
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Mailing Address - Street 1:860 OMNI BLVD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606
Mailing Address - Country:US
Mailing Address - Phone:757-232-8777
Mailing Address - Fax:757-232-8866
Practice Address - Street 1:351 EDWIN DRIVE
Practice Address - Street 2:SUITE 102
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462
Practice Address - Country:US
Practice Address - Phone:757-499-5550
Practice Address - Fax:757-473-0919
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2012-05-24
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Provider Licenses
StateLicense IDTaxonomies
VA0110840456363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1255329900Medicaid
VA583898Medicare UPIN
VA003279T44Medicare PIN