Provider Demographics
NPI:1205961596
Name:ROSS, WENDY GILLIAN (RPAC)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:GILLIAN
Last Name:ROSS
Suffix:
Gender:F
Credentials:RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1995 NESCONSET HWY
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-1002
Mailing Address - Country:US
Mailing Address - Phone:631-731-0449
Mailing Address - Fax:
Practice Address - Street 1:1272 E MAIN ST
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2583
Practice Address - Country:US
Practice Address - Phone:631-574-7360
Practice Address - Fax:631-591-3900
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004544363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant