Provider Demographics
NPI:1437528338
Name:ROSS, CLIFFORD BYRON II
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:BYRON
Last Name:ROSS
Suffix:II
Gender:M
Credentials:
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 505
Mailing Address - Street 2:
Mailing Address - City:LA CONNER
Mailing Address - State:WA
Mailing Address - Zip Code:98257-0505
Mailing Address - Country:US
Mailing Address - Phone:360-873-8356
Mailing Address - Fax:360-899-4641
Practice Address - Street 1:2116 E SECTION ST STE B
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-9124
Practice Address - Country:US
Practice Address - Phone:360-873-8356
Practice Address - Fax:360-899-4641
Is Sole Proprietor?:No
Enumeration Date:2015-09-21
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160570116225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant