Provider Demographics
NPI:1538812805
Name:ROSS, BROOK LYNN (PA-C)
Entity type:Individual
Prefix:
First Name:BROOK
Middle Name:LYNN
Last Name:ROSS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BROOK
Other - Middle Name:LYNN
Other - Last Name:RODDENBERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3333 RIVERWOOD PKWY SE STE 250
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-3304
Mailing Address - Country:US
Mailing Address - Phone:770-914-0116
Mailing Address - Fax:
Practice Address - Street 1:1240 EAGLES LANDING PKWY STE 110
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-5173
Practice Address - Country:US
Practice Address - Phone:770-389-3855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-27
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-13447363A00000X
FLPA9115415363AM0700X
GA12578363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical