Provider Demographics
NPI:1447204896
Name:TISRON, ROSS E (NP)
Entity Type:Individual
Prefix:
First Name:ROSS
Middle Name:E
Last Name:TISRON
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Gender:M
Credentials:NP
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Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:BOX 42
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-7806
Mailing Address - Fax:269-341-8743
Practice Address - Street 1:200 N PARK ST
Practice Address - Street 2:WEST MICHIGAN CANCER CENTER
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-3731
Practice Address - Country:US
Practice Address - Phone:269-382-2500
Practice Address - Fax:269-373-7478
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2023-03-07
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Provider Licenses
StateLicense IDTaxonomies
MI4704162218363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4868770Medicaid
MT1318509OtherDEA