Basic Information
| Provider Information | |||||||||
| NPI: | 1215048210 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSS | ||||||||
| FirstName: | CHERYL | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 188 | ||||||||
| Address2: | |||||||||
| City: | MARANA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856530188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206824111 | ||||||||
| FaxNumber: | 5206823817 | ||||||||
| Practice Location | |||||||||
| Address1: | 13395 N MARANA MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MARANA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856537008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206824111 | ||||||||
| FaxNumber: | 5206823817 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 09/07/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN059578 | AZ | N | Nursing Service Providers | Registered Nurse | 363LF0000X | AP2494 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LX0001X | AP0154 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 402363 | 05 | AZ | MEDICAID |