Provider Demographics
NPI:1417263252
Name:ROSS, EDWARD M (LPTA)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:M
Last Name:ROSS
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 S NORTHPARK LN
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64801-8426
Mailing Address - Country:US
Mailing Address - Phone:417-623-4313
Mailing Address - Fax:417-621-0129
Practice Address - Street 1:201 S NORTHPARK LN
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-8426
Practice Address - Country:US
Practice Address - Phone:417-623-4313
Practice Address - Fax:417-621-0129
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-30
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO114921225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant