Provider Demographics
NPI:1881689917
Name:ROOSE, TIMOTHY (CRNA)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:ROOSE
Suffix:
Gender:M
Credentials:CRNA
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 1303
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-1303
Mailing Address - Country:US
Mailing Address - Phone:912-538-5359
Mailing Address - Fax:912-538-5228
Practice Address - Street 1:ONE MEADOWS PKWY
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8759
Practice Address - Country:US
Practice Address - Phone:912-538-5359
Practice Address - Fax:912-538-5228
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAR082998367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000550151BMedicaid
GA000550151BMedicaid