Healthcare Provider Details

I. General information

NPI: 1174773808
Provider Name (Legal Business Name): STACY NICOLE ROSS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2008
Last Update Date: 07/16/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 E HERNDON AVE STE 230
FRESNO CA
93720-3392
US

IV. Provider business mailing address

1630 E HERNDON AVE
FRESNO CA
93720-3305
US

V. Phone/Fax

Practice location:
  • Phone: 559-450-2663
  • Fax: 559-450-2724
Mailing address:
  • Phone: 559-256-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 19958
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: