Provider Demographics
NPI:1841311156
Name:ROSS, MIA (NP)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2233 STATE ROUTE 86
Mailing Address - Street 2:
Mailing Address - City:SARANAC LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12983-5644
Mailing Address - Country:US
Mailing Address - Phone:518-897-2879
Mailing Address - Fax:518-891-5248
Practice Address - Street 1:2233 STATE ROUTE 86
Practice Address - Street 2:ONCOLOGY DEPT
Practice Address - City:SARANAC LAKE
Practice Address - State:NY
Practice Address - Zip Code:12983-5644
Practice Address - Country:US
Practice Address - Phone:518-897-2879
Practice Address - Fax:518-891-5248
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF302382363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00363213Medicaid
NYF302382OtherLICENSE
NY141731786OtherTAX ID
NY141731786OtherTAX ID
NYS70875Medicare PIN
NY141731786OtherTAX ID
NY70138AMedicare ID - Type UnspecifiedMEDICARE GROUP NUMBER