Provider Demographics
NPI:1417937020
Name:ROTH-BOWERSOCK, ROSE M (PNP-BC)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:M
Last Name:ROTH-BOWERSOCK
Suffix:
Gender:F
Credentials:PNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 HEALTH PKWY
Mailing Address - Street 2:SUITE E
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-8242
Mailing Address - Country:US
Mailing Address - Phone:269-655-3090
Mailing Address - Fax:269-655-0763
Practice Address - Street 1:451 HEALTH PKWY
Practice Address - Street 2:SUITE E
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-8242
Practice Address - Country:US
Practice Address - Phone:269-655-3090
Practice Address - Fax:269-655-0763
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI470420936363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1417937020Medicaid
MI4469434Medicaid
MI1235131137OtherBCBSM - BLH
MI1235131137OtherBCBSM - BLH
MI4469434Medicaid
MIH06012727 - BLHMedicare PIN