Provider Demographics
NPI:1992680276
Name:ROSS, CLYDE E
Entity type:Individual
Prefix:
First Name:CLYDE
Middle Name:E
Last Name:ROSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-0000
Mailing Address - Country:US
Mailing Address - Phone:401-475-0636
Mailing Address - Fax:401-205-1026
Practice Address - Street 1:225 MAIN STREET
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-0000
Practice Address - Country:US
Practice Address - Phone:401-475-0636
Practice Address - Fax:401-205-1026
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-07
Last Update Date:2025-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI2218047172V00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker