Provider Demographics
NPI:1922191782
Name:ROSEN, STEPHANIE ANNE (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANNE
Last Name:ROSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 SAINT MICHAELS DR
Mailing Address - Street 2:SUITE 903
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7619
Mailing Address - Country:US
Mailing Address - Phone:505-820-5703
Mailing Address - Fax:505-820-2461
Practice Address - Street 1:455 SAINT MICHAELS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7601
Practice Address - Country:US
Practice Address - Phone:505-820-5703
Practice Address - Fax:505-820-2461
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2007-0482207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM68405529Medicaid
NM68405529Medicaid