Provider Demographics
NPI:1306202429
Name:MCCOLLUM, ROSS (CRNA)
Entity Type:Individual
Prefix:
First Name:ROSS
Middle Name:
Last Name:MCCOLLUM
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4631 MACARTHUR BLVD NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20007-7531
Mailing Address - Country:US
Mailing Address - Phone:714-309-7912
Mailing Address - Fax:
Practice Address - Street 1:4631 MACARTHUR BLVD NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20007-7531
Practice Address - Country:US
Practice Address - Phone:714-309-7912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-05
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1019944390200000X
TXAP131015367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program