Provider Demographics
NPI:1669451589
Name:ROSE, VICKI L (PA)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:L
Last Name:ROSE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8674
Mailing Address - Street 2:1230 E MAIN ST
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56002-8674
Mailing Address - Country:US
Mailing Address - Phone:507-625-1811
Mailing Address - Fax:
Practice Address - Street 1:1230 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56002-8674
Practice Address - Country:US
Practice Address - Phone:507-625-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9544363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2409706OtherAMERICAS PPO
MNNA2951024933OtherPREFERRED ONE
MNHP30956OtherHEALTH PARTNERS
MN0109946OtherMEDICA
MN57B74ROOtherBCBS
MN140087OtherUCARE
41084933956001C220OtherCHAMPUS
MN741190100Medicaid
MN2409706OtherAMERICAS PPO
P16289Medicare UPIN