Healthcare Provider Details

I. General information

NPI: 1679120331
Provider Name (Legal Business Name): JUSTINE MARY ROSS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2019
Last Update Date: 06/30/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 LAC DE VILLE BLVD BLDG D
ROCHESTER NY
14618-5647
US

IV. Provider business mailing address

65 W BROAD ST APT 803
ROCHESTER NY
14614-2218
US

V. Phone/Fax

Practice location:
  • Phone: 585-275-1395
  • Fax:
Mailing address:
  • Phone: 413-883-8097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License Number24079
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: