Provider Demographics
NPI:1376021097
Name:ROSS, MIKEL (AGNP-BC)
Entity Type:Individual
Prefix:
First Name:MIKEL
Middle Name:
Last Name:ROSS
Suffix:
Gender:M
Credentials:AGNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 E 68TH ST APT 4B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-5629
Mailing Address - Country:US
Mailing Address - Phone:314-302-7369
Mailing Address - Fax:
Practice Address - Street 1:345 E 68TH ST APT 4B
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-5629
Practice Address - Country:US
Practice Address - Phone:314-302-7369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-03
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF308795363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health