Provider Demographics
NPI:1245873330
Name:ROSS, MYCHAL JORDAN
Entity type:Individual
Prefix:
First Name:MYCHAL
Middle Name:JORDAN
Last Name:ROSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:837 MCKINLEY ST
Mailing Address - Street 2:
Mailing Address - City:HARWICK
Mailing Address - State:PA
Mailing Address - Zip Code:15049-8927
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:102 TECHNOLOGY DR STE 110A
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:PA
Practice Address - Zip Code:16001-1784
Practice Address - Country:US
Practice Address - Phone:833-917-0873
Practice Address - Fax:724-482-0185
Is Sole Proprietor?:No
Enumeration Date:2019-10-22
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP021289363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily