Provider Demographics
NPI:1134702525
Name:ROOSE, MOLLY K (PA-C)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:K
Last Name:ROOSE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:K
Other - Last Name:BENDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3519 RICHMOND DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-5995
Mailing Address - Country:US
Mailing Address - Phone:970-204-0300
Mailing Address - Fax:970-226-9041
Practice Address - Street 1:1683 MAIN ST
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CO
Practice Address - Zip Code:80550-7921
Practice Address - Country:US
Practice Address - Phone:970-400-7618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-03
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0006591363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant