Provider Demographics
NPI:1992937460
Name:ROSS, STACEY (NP)
Entity type:Individual
Prefix:
First Name:STACEY
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 1:1940 5TH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-2364
Mailing Address - Country:US
Mailing Address - Phone:619-683-2820
Mailing Address - Fax:619-683-2825
Practice Address - Street 1:1940 5TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2364
Practice Address - Country:US
Practice Address - Phone:619-683-2820
Practice Address - Fax:619-683-2825
Is Sole Proprietor?:No
Enumeration Date:2009-08-18
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA497900363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner