Provider Demographics
NPI:1366832115
Name:ROSS, AMANDA KATHRYN (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:KATHRYN
Last Name:ROSS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1158 ISLAND LAKE BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:WELCH
Mailing Address - State:MN
Mailing Address - Zip Code:55089
Mailing Address - Country:US
Mailing Address - Phone:651-385-4148
Mailing Address - Fax:
Practice Address - Street 1:7841 AMANA TRL
Practice Address - Street 2:
Practice Address - City:INVER GROVE HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55077-2609
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-02
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11724363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant