1114198702 NPI number — MICHELLE LYNN ROSS PA-C

Table of content: MICHELLE LYNN ROSS PA-C (NPI 1114198702)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114198702 NPI number — MICHELLE LYNN ROSS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSS
Provider First Name:
MICHELLE
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114198702
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
219 W 17TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOPKINSVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42240-1911
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-886-5141
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1724 KENTON ST STE 1C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOPKINSVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42240-1981
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-886-5141
Provider Business Practice Location Address Fax Number:
270-885-1877
Provider Enumeration Date:
03/21/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  1584 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: TC683 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: PA2332 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7100523490 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".