Provider Demographics
NPI:1700029659
Name:HALLER, ROSS J (PA)
Entity Type:Individual
Prefix:MR
First Name:ROSS
Middle Name:J
Last Name:HALLER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1 VETERANS DRIVE
Mailing Address - Street 2:UROLOGY 112D
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417
Mailing Address - Country:US
Mailing Address - Phone:612-467-1173
Mailing Address - Fax:
Practice Address - Street 1:1 VETERANS DR
Practice Address - Street 2:UROLOGY 112D
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417-2309
Practice Address - Country:US
Practice Address - Phone:612-467-1173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-08
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9076363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant