Provider Demographics
NPI:1205507134
Name:ROSS, COLIN MICHAEL (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MR
First Name:COLIN
Middle Name:MICHAEL
Last Name:ROSS
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:782 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CAPE VINCENT
Mailing Address - State:NY
Mailing Address - Zip Code:13618-2204
Mailing Address - Country:US
Mailing Address - Phone:315-654-2530
Mailing Address - Fax:
Practice Address - Street 1:782 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CAPE VINCENT
Practice Address - State:NY
Practice Address - Zip Code:13618-2204
Practice Address - Country:US
Practice Address - Phone:315-654-2530
Practice Address - Fax:315-654-2832
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026718363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06822820Medicaid