Provider Demographics
NPI:1508820648
Name:ROSS, MICHAEL M (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:M
Last Name:ROSS
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:PO BOX 4039
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-4039
Mailing Address - Country:US
Mailing Address - Phone:714-571-5000
Mailing Address - Fax:714-919-8836
Practice Address - Street 1:315 N 3RD AVE STE 207
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-1917
Practice Address - Country:US
Practice Address - Phone:626-967-4469
Practice Address - Fax:626-967-4889
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13332363A00000X, 363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR36533Medicare UPIN