Provider Demographics
NPI:1679120331
Name:ROSS, JUSTINE MARY (PA)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:MARY
Last Name:ROSS
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:65 W BROAD ST APT 803
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14614-2218
Mailing Address - Country:US
Mailing Address - Phone:413-883-8097
Mailing Address - Fax:
Practice Address - Street 1:4901 LAC DE VILLE BLVD BLDG D
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-5647
Practice Address - Country:US
Practice Address - Phone:585-275-1395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-19
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY24079207XP3100X
NY363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery