Provider Demographics
NPI:1720762974
Name:ROSS, COLE WESTON
Entity Type:Individual
Prefix:
First Name:COLE
Middle Name:WESTON
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 1:1637 THEMIS ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-5221
Mailing Address - Country:US
Mailing Address - Phone:573-803-8346
Mailing Address - Fax:
Practice Address - Street 1:1723 BROADWAY ST STE 410
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-4556
Practice Address - Country:US
Practice Address - Phone:573-332-7746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-09
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023021732363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily