Provider Demographics
NPI:1134100563
Name:ROSS, DAVID G (PA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:G
Last Name:ROSS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13939 E 14TH ST
Mailing Address - Street 2:SUITE 150
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-2601
Mailing Address - Country:US
Mailing Address - Phone:510-343-8300
Mailing Address - Fax:510-343-8301
Practice Address - Street 1:13939 E 14TH ST
Practice Address - Street 2:SUITE 150
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-2601
Practice Address - Country:US
Practice Address - Phone:510-343-8300
Practice Address - Fax:510-343-8301
Is Sole Proprietor?:No
Enumeration Date:2005-11-11
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA12228363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPA122280OtherBLUE SHIELD
CAOPA122280Medicaid
P53382Medicare UPIN
CAOPA122280OtherBLUE SHIELD
CA0PA122281Medicare PIN