Provider Demographics
NPI:1821642232
Name:ROSE, PAUL GARY
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:GARY
Last Name:ROSE
Suffix:
Gender:M
Credentials:
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 200
Mailing Address - Street 2:
Mailing Address - City:ONEIDA
Mailing Address - State:WI
Mailing Address - Zip Code:54155-0200
Mailing Address - Country:US
Mailing Address - Phone:920-632-7031
Mailing Address - Fax:888-959-6350
Practice Address - Street 1:N6158 LAMBIE RD
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-6705
Practice Address - Country:US
Practice Address - Phone:920-632-7031
Practice Address - Fax:888-959-6350
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-25
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor