Provider Demographics
NPI:1457654519
Name:ROSS, MARY A (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:ROSS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2100 W IOWA AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018-2736
Mailing Address - Country:US
Mailing Address - Phone:405-224-2100
Mailing Address - Fax:405-779-2244
Practice Address - Street 1:2100 W IOWA AVE
Practice Address - Street 2:SUITE A
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-2736
Practice Address - Country:US
Practice Address - Phone:405-224-2100
Practice Address - Fax:405-779-2244
Is Sole Proprietor?:No
Enumeration Date:2010-12-13
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK1949363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP00937992OtherMEDICARE RAIL ROAD
OK200315730AMedicaid
OK200315730AMedicaid