Provider Demographics
NPI:1235102336
Name:ROSE, REBECCA A (PA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
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 1:3 MAPLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WOLFEBORO
Mailing Address - State:NH
Mailing Address - Zip Code:03894-4024
Mailing Address - Country:US
Mailing Address - Phone:603-455-4037
Mailing Address - Fax:
Practice Address - Street 1:25A JUNE ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:ME
Practice Address - Zip Code:04073-2642
Practice Address - Country:US
Practice Address - Phone:207-490-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA2196363A00000X
NH0457 P363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30332536Medicaid
NH0400503YPNH01OtherANTHEM
NH30332536Medicaid