MEDICARE: MIKAL SOO ROSS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA20011	TX

General Provider Information

NPI Number	:	1982409041
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIKAL SOO ROSS

Provider Business Mailing Address
First Line	:	4420 W LOVERS LN
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75209-3130
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4420 W LOVERS LN
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75209-3130
Country	:	US
Telephone Number	:	214-373-7546
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2025
Last Update Date	:	05/30/2026

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Directions to “ MIKAL SOO ROSS ” Practice Location

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