Provider Demographics
NPI:1477655223
Name:ROOS, MICHAEL (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:ROOS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 S NELLIS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-6215
Mailing Address - Country:US
Mailing Address - Phone:702-254-6821
Mailing Address - Fax:702-243-5012
Practice Address - Street 1:1420 E CALVADA BLVD STE 100
Practice Address - Street 2:
Practice Address - City:PAHRUMP
Practice Address - State:NV
Practice Address - Zip Code:89048-3975
Practice Address - Country:US
Practice Address - Phone:775-727-0900
Practice Address - Fax:702-727-0902
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6711363AM0700X
NVPA0347363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVPA0347OtherNV STATE MEDICAL LICENSE
NV1477655223Medicaid
NV70003254OtherRAILROAD MEDICARE
NVPA0347OtherNV STATE MEDICAL LICENSE
P41634Medicare UPIN