Provider Demographics
NPI:1942691266
Name:ROSE, BOBBY G (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:BOBBY
Middle Name:G
Last Name:ROSE
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 LOMA AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-6077
Mailing Address - Country:US
Mailing Address - Phone:562-882-4668
Mailing Address - Fax:
Practice Address - Street 1:1955 LONG BEACH BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-5501
Practice Address - Country:US
Practice Address - Phone:562-437-6717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-09
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95004731363LP0808X
CA345573163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse