Provider Demographics
NPI:1457639072
Name:ROSE, OLIVIA DENISE (PA-C)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:DENISE
Last Name:ROSE
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 1:100 15TH ST NW
Mailing Address - Street 2:SUITE A
Mailing Address - City:NORTON
Mailing Address - State:VA
Mailing Address - Zip Code:24273-1616
Mailing Address - Country:US
Mailing Address - Phone:276-439-1840
Mailing Address - Fax:276-439-1845
Practice Address - Street 1:100 15TH ST NW
Practice Address - Street 2:SUITE A
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273-1616
Practice Address - Country:US
Practice Address - Phone:276-439-1840
Practice Address - Fax:276-439-1845
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-31
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004954363A00000X
KY1642363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1457639072Medicaid
VA1457639072Medicaid