Provider Demographics
NPI:1619020005
Name:ROSE, SHERRYL K (DO)
Entity Type:Individual
Prefix:DR
First Name:SHERRYL
Middle Name:K
Last Name:ROSE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2153 N LEANN WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1227
Mailing Address - Country:US
Mailing Address - Phone:208-888-9521
Mailing Address - Fax:
Practice Address - Street 1:2153 N LEANN WAY
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1227
Practice Address - Country:US
Practice Address - Phone:208-888-9521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO25207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDEO3554Medicare UPIN