Provider Demographics
NPI:1861077109
Name:ROSS, KATHERINE GRACE (PA)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:GRACE
Last Name:ROSS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 E 7TH ST APT 6
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-2544
Mailing Address - Country:US
Mailing Address - Phone:501-317-5572
Mailing Address - Fax:
Practice Address - Street 1:11321 I-30 FRONTAGE RD.
Practice Address - Street 2:SUITE 200
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72209
Practice Address - Country:US
Practice Address - Phone:501-455-7009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-17
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
ARPA-958363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered