Provider Demographics
NPI:1184055030
Name:ROSS, ELISHA ANN (PA-C)
Entity type:Individual
Prefix:
First Name:ELISHA
Middle Name:ANN
Last Name:ROSS
Suffix:
Gender:F
Credentials:PA-C
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 191050
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-1050
Mailing Address - Country:US
Mailing Address - Phone:208-955-6522
Mailing Address - Fax:
Practice Address - Street 1:3597 E MONARCH SKY LN
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-1053
Practice Address - Country:US
Practice Address - Phone:702-848-2256
Practice Address - Fax:702-485-6746
Is Sole Proprietor?:No
Enumeration Date:2013-12-03
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1137363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant