Provider Demographics
NPI:1740458827
Name:OBENAUER, ROSS (PA-C)
Entity type:Individual
Prefix:
First Name:ROSS
Middle Name:
Last Name:OBENAUER
Suffix:
Gender:M
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 1:3800 SOUTH FIGUEROA STREET
Mailing Address - Street 2:ST JOHN'S WELL CHILD CENTER
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90037
Mailing Address - Country:US
Mailing Address - Phone:323-541-1600
Mailing Address - Fax:
Practice Address - Street 1:3800 SOUTH FIGUEROA STREET
Practice Address - Street 2:ST JOHN'S WELL CHILD CENTER
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037
Practice Address - Country:US
Practice Address - Phone:323-541-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-12
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17261363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant