Provider Demographics
NPI:1265041974
Name:ROSS, DEJUAN SR
Entity Type:Individual
Prefix:
First Name:DEJUAN
Middle Name:
Last Name:ROSS
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12325 CATALINA AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70814-7516
Mailing Address - Country:US
Mailing Address - Phone:225-802-0865
Mailing Address - Fax:
Practice Address - Street 1:12325 CATALINA AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70814-7516
Practice Address - Country:US
Practice Address - Phone:225-802-0865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-28
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)