Provider Demographics
NPI:1568550317
Name:ROSS, PHYLLIS (PHYSICIAN ASSITANT)
Entity Type:Individual
Prefix:MISS
First Name:PHYLLIS
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:PHYSICIAN ASSITANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1500 W WEST COVINA PKWY
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-2703
Mailing Address - Country:US
Mailing Address - Phone:626-926-3702
Mailing Address - Fax:626-960-3726
Practice Address - Street 1:777 FLOWER ST STE A
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91201-3000
Practice Address - Country:US
Practice Address - Phone:818-637-2000
Practice Address - Fax:818-242-8761
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA12182363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS11581Medicare UPIN
CAWPA12182CMedicare PIN