Provider Demographics
NPI:1477536530
Name:ROSE, DAVID BERTRAND (PA)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:BERTRAND
Last Name:ROSE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CMR 427, BOX 2221
Mailing Address - Street 2:
Mailing Address - City:VICENZA
Mailing Address - State:VENETO
Mailing Address - Zip Code:APO AE 09630
Mailing Address - Country:IT
Mailing Address - Phone:01139044-458-3299
Mailing Address - Fax:01139044-471-8210
Practice Address - Street 1:369 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-3613
Practice Address - Country:US
Practice Address - Phone:317-881-2958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1001247363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical