Provider Demographics
NPI:1821269762
Name:ROSEN, WAYNE R (CPO, CPED,PA)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:R
Last Name:ROSEN
Suffix:
Gender:M
Credentials:CPO, CPED,PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9921 PINES BLVD
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-6174
Mailing Address - Country:US
Mailing Address - Phone:954-447-7779
Mailing Address - Fax:954-447-7782
Practice Address - Street 1:9921 PINES BLVD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-6174
Practice Address - Country:US
Practice Address - Phone:954-447-7779
Practice Address - Fax:954-447-7782
Is Sole Proprietor?:No
Enumeration Date:2008-03-19
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 00039222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL032584800Medicaid
FL032584800Medicaid