Basic Information
| Provider Information | |||||||||
| NPI: | 1528454238 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSS-LI | ||||||||
| FirstName: | SHELLEY | ||||||||
| MiddleName: | KATHERINE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROSS | ||||||||
| OtherFirstName: | SHELLEY | ||||||||
| OtherMiddleName: | KATHERINE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 325 DISTEL CIR | ||||||||
| Address2: | |||||||||
| City: | LOS ALTOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940221408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9257561192 | ||||||||
| FaxNumber: | 9257797220 | ||||||||
| Practice Location | |||||||||
| Address1: | 3901 LONE TREE WAY STE 211 | ||||||||
| Address2: | |||||||||
| City: | ANTIOCH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945096200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9257561192 | ||||||||
| FaxNumber: | 9257797220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2015 | ||||||||
| LastUpdateDate: | 08/19/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 169120 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208M00000X | A169120 | CA | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 1182543 | 01 | CA | AMERICAN BOARD OF PEDIATRICS | OTHER | A169120 | 01 | CA | STATE MEDICAL LICENSE | OTHER |