Provider Demographics
NPI:1154670362
Name:ROSE, THOMAS DAVIS SR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:DAVIS
Last Name:ROSE
Suffix:SR
Gender:M
Credentials:PA-C
Other - Prefix:MR
Other - First Name:THOMAS
Other - Middle Name:DAVIS
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:605 LORD NELSON CT
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-7912
Mailing Address - Country:US
Mailing Address - Phone:757-549-5210
Mailing Address - Fax:757-549-5210
Practice Address - Street 1:605 LORD NELSON CT
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-7912
Practice Address - Country:US
Practice Address - Phone:757-549-5210
Practice Address - Fax:757-549-5210
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-04
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0001884363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical