Provider Demographics
NPI:1629055868
Name:ROSA, PATRICIO (MD)
Entity Type:Individual
Prefix:
First Name:PATRICIO
Middle Name:
Last Name:ROSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1665 QUIRKS RUN RD
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-8830
Mailing Address - Country:US
Mailing Address - Phone:859-236-4269
Mailing Address - Fax:859-545-4945
Practice Address - Street 1:1010 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-3706
Practice Address - Country:US
Practice Address - Phone:270-706-5171
Practice Address - Fax:270-706-5738
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2021-12-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME1119382086S0129X, 2086S0129X
VA01012457972086S0129X
FLME853812086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL57913OtherBCBS
FL267826800Medicaid
FL57913OtherBCBS
VA1629055868Medicaid
FL267826800Medicaid
VAP00731324Medicare PIN