Provider Demographics
NPI:1558045856
Name:ROSE, DONOVAN JACOB (PA-C)
Entity Type:Individual
Prefix:
First Name:DONOVAN
Middle Name:JACOB
Last Name:ROSE
Suffix:
Gender:M
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 1:1870 WINTON RD S STE 100
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-4011
Mailing Address - Country:US
Mailing Address - Phone:585-276-0830
Mailing Address - Fax:
Practice Address - Street 1:1870 WINTON RD S STE 100
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-4011
Practice Address - Country:US
Practice Address - Phone:585-276-0830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-15
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical