Basic Information
| Provider Information | |||||||||
| NPI: | 1699923748 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSS | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | FAY | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | B.S., MSPAS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HUENINK | ||||||||
| OtherFirstName: | ANGELA | ||||||||
| OtherMiddleName: | FAY | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1801 N SENATE BLVD | ||||||||
| Address2: | STE 355 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462021252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179248425 | ||||||||
| FaxNumber: | 3179248424 | ||||||||
| Practice Location | |||||||||
| Address1: | 1801 N. SENATE BLVD | ||||||||
| Address2: | SUITE 355 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462021252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179248425 | ||||||||
| FaxNumber: | 3179248424 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2008 | ||||||||
| LastUpdateDate: | 02/24/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 10001019A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.