Provider Demographics
NPI:1306859962
Name:ROSE, JOHN W (ARNP CNM)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:ROSE
Suffix:
Gender:M
Credentials:ARNP CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9605 SANDIFUR PKWY
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-8028
Mailing Address - Country:US
Mailing Address - Phone:509-942-3627
Mailing Address - Fax:509-547-0827
Practice Address - Street 1:945 GOETHALS DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352
Practice Address - Country:US
Practice Address - Phone:509-942-3627
Practice Address - Fax:509-942-2340
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30003919363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8896839OtherMEDICARE
WA9618257Medicaid
WA8869063Medicare PIN