Healthcare Provider Details

I. General information

NPI: 1144870163
Provider Name (Legal Business Name): SCOTT ROSS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2019
Last Update Date: 02/27/2024
Certification Date: 02/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 PINION DR
USAF ACADEMY CO
80840-4000
US

IV. Provider business mailing address

15643 W MONTECITO AVE
GOODYEAR AZ
85395-7786
US

V. Phone/Fax

Practice location:
  • Phone: 719-524-2273
  • Fax:
Mailing address:
  • Phone: 480-282-1909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number7666
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA.0008239
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: