Basic Information
| Provider Information | |||||||||
| NPI: | 1184055030 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSS | ||||||||
| FirstName: | ELISHA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 191050 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837191050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089556522 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3597 E MONARCH SKY LN | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836461053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028482256 | ||||||||
| FaxNumber: | 7024856746 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2013 | ||||||||
| LastUpdateDate: | 12/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA-1137 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.