Provider Demographics
NPI:1891311312
Name:ROSS, TAYLOR (PA)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14214 BALLANTYNE LAKE RD
Practice Address - Street 2:STE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-3372
Practice Address - Country:US
Practice Address - Phone:704-667-2650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-20
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-09687363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant