Provider Demographics
NPI:1376317271
Name:ROOSE, AILIS (PA-C)
Entity Type:Individual
Prefix:
First Name:AILIS
Middle Name:
Last Name:ROOSE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 WARDS HILL RD
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:MD
Mailing Address - Zip Code:21912-1248
Mailing Address - Country:US
Mailing Address - Phone:443-945-6194
Mailing Address - Fax:
Practice Address - Street 1:17500 W GRAND PKWY S
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-2562
Practice Address - Country:US
Practice Address - Phone:832-655-4141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-10
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17257363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical