Provider Demographics
NPI:1326180837
Name:LAROSE, ROGER WALTER (MA)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:WALTER
Last Name:LAROSE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 CARSON VALLEY WAY
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-1443
Mailing Address - Country:US
Mailing Address - Phone:505-297-9574
Mailing Address - Fax:
Practice Address - Street 1:58 CARSON VALLEY WAY
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87508-1443
Practice Address - Country:US
Practice Address - Phone:505-297-9574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMAUD6535237600000X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK10740Medicare ID - Type Unspecified