Provider Demographics
NPI:1629003736
Name:ROSE, ANTHONY JOSEPH (PA-C)
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:JOSEPH
Last Name:ROSE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 W ERIE AVE
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72601-3539
Mailing Address - Country:US
Mailing Address - Phone:870-741-8289
Mailing Address - Fax:870-741-0308
Practice Address - Street 1:224 WEST ERIE
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601
Practice Address - Country:US
Practice Address - Phone:870-741-8289
Practice Address - Fax:870-741-0308
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002770363A00000X
NM92PA15363A00000X
ARPA-421363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM98122Medicaid
R13221Medicare UPIN