Provider Demographics
NPI:1447792619
Name:ROSS, BRIAN JOSHUA
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:JOSHUA
Last Name:ROSS
Suffix:
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 1:7272 MANSON ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-5713
Mailing Address - Country:US
Mailing Address - Phone:210-426-7235
Mailing Address - Fax:
Practice Address - Street 1:6905 HARRIS AVE
Practice Address - Street 2:
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734
Practice Address - Country:US
Practice Address - Phone:808-257-3365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-05
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
TX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant