Provider Demographics
NPI:1306890249
Name:ROSS, MARC (PA)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:ROSS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S VAN BRUNT ST
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-4604
Mailing Address - Country:US
Mailing Address - Phone:201-569-2770
Mailing Address - Fax:201-569-1774
Practice Address - Street 1:401 S VAN BRUNT ST
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-4604
Practice Address - Country:US
Practice Address - Phone:201-569-2770
Practice Address - Fax:201-569-1774
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00116500363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q15942Medicare UPIN
079037PF5Medicare PIN