Healthcare Provider Details

I. General information

NPI: 1447204896
Provider Name (Legal Business Name): ROSS E TISRON NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N PARK ST WEST MICHIGAN CANCER CENTER
KALAMAZOO MI
49007-3731
US

IV. Provider business mailing address

601 JOHN ST BOX 42
KALAMAZOO MI
49007-5341
US

V. Phone/Fax

Practice location:
  • Phone: 269-382-2500
  • Fax: 269-373-7478
Mailing address:
  • Phone: 269-341-7806
  • Fax: 269-341-8743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704162218
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: