Provider Demographics
NPI:1447890066
Name:ROSS, MATTHEW (FNP-C)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:ROSS
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3170 KETTERING BLVD BLDG B3
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3188
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:1880 E US HIGHWAY 36
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:OH
Practice Address - Zip Code:43078-9600
Practice Address - Country:US
Practice Address - Phone:937-991-3188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-11
Last Update Date:2023-10-05
Deactivation Date:2020-03-04
Deactivation Code:
Reactivation Date:2020-03-18
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.026445363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily