Provider Demographics
NPI:1174010813
Name:ROSE, HEATHER LEE (PA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LEE
Last Name:ROSE
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1025 MOREHEAD MEDICAL DR
Practice Address - Street 2:STE 600
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2963
Practice Address - Country:US
Practice Address - Phone:704-355-8816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-18
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-07860363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant