Provider Demographics
NPI:1396853396
Name:ROSS, MICHAEL (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:ROSS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22000
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76902-7200
Mailing Address - Country:US
Mailing Address - Phone:325-942-8611
Mailing Address - Fax:325-481-2165
Practice Address - Street 1:3502 KNICKERBOCKER RD
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-7671
Practice Address - Country:US
Practice Address - Phone:325-942-8611
Practice Address - Fax:325-659-0180
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04079363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX189528605Medicaid
TX189528607Medicaid
TX189528606Medicaid
TX189528608Medicaid
TX189528608Medicaid
TX189528607Medicaid
TXTXB157589Medicare PIN
TX189528605Medicaid
TX189528606Medicaid
TXTXB157587Medicare PIN