Provider Demographics
NPI:1861994139
Name:ROSS, TREVOR CHARLES
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:CHARLES
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 1:6215 SW CORBETT AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3043 NE 28TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN CITY
Practice Address - State:OR
Practice Address - Zip Code:97367-4518
Practice Address - Country:US
Practice Address - Phone:541-996-7375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-02
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORP2-0012323390200000X
ORRPH-00175441835C0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835C0205XPharmacy Service ProvidersPharmacistCritical Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program