Provider Demographics
NPI:1770882144
Name:ROSS, MATTHEW A (MSN, APRN, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:A
Last Name:ROSS
Suffix:
Gender:M
Credentials:MSN, APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4643 SHERMAN DR NE
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-5360
Mailing Address - Country:US
Mailing Address - Phone:218-209-7528
Mailing Address - Fax:
Practice Address - Street 1:4643 SHERMAN DR NE
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-5360
Practice Address - Country:US
Practice Address - Phone:218-209-7528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-24
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-186703-5163W00000X
MN12156363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN12156OtherCERTIFIED NURSE PRACTITIONER