Provider Demographics
NPI:1497059034
Name:ROSE, BLAIR NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:BLAIR
Middle Name:NICOLE
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 1:804 ANDERSONVILLE LN
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-5304
Mailing Address - Country:US
Mailing Address - Phone:972-742-6091
Mailing Address - Fax:
Practice Address - Street 1:1717 MAIN ST
Practice Address - Street 2:5200
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75201-4612
Practice Address - Country:US
Practice Address - Phone:214-712-2444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-22
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical