Provider Demographics
NPI:1871971234
Name:ROSS, SHELBY
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1498 SE TECH CENTER PL
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9591
Mailing Address - Country:US
Mailing Address - Phone:503-494-3633
Mailing Address - Fax:
Practice Address - Street 1:1498 SE TECH CENTER PL
Practice Address - Street 2:SUITE 240
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-9591
Practice Address - Country:US
Practice Address - Phone:360-597-1309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-18
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60705470363A00000X
ORPA179810363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant