Provider Demographics
NPI:1578520417
Name:ROSS, TRAVIS (PA-C)
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:
Last Name:ROSS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3622 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOPE MILLS
Mailing Address - State:NC
Mailing Address - Zip Code:28348-1937
Mailing Address - Country:US
Mailing Address - Phone:910-423-7771
Mailing Address - Fax:910-423-4177
Practice Address - Street 1:3622 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HOPE MILLS
Practice Address - State:NC
Practice Address - Zip Code:28348-1937
Practice Address - Country:US
Practice Address - Phone:910-423-7771
Practice Address - Fax:910-423-4177
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001000298363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89012YEMedicaid
NC89012YEMedicaid
NC2765244Medicare ID - Type Unspecified