Provider Demographics
NPI:1578647012
Name:PFAFF, ROSS M (PTA, ATC)
Entity Type:Individual
Prefix:MR
First Name:ROSS
Middle Name:M
Last Name:PFAFF
Suffix:
Gender:M
Credentials:PTA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12456 GREY TWIG DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-5546
Mailing Address - Country:US
Mailing Address - Phone:317-965-7221
Mailing Address - Fax:
Practice Address - Street 1:5801 BRYANT IRVIN RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4209
Practice Address - Country:US
Practice Address - Phone:817-988-6873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001064A174400000X
TX2092898225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No174400000XOther Service ProvidersSpecialist