Provider Demographics
NPI:1134757990
Name:ROOSE, ALIS SERGEEVNA-SOKOLOVA (DO)
Entity type:Individual
Prefix:
First Name:ALIS
Middle Name:SERGEEVNA-SOKOLOVA
Last Name:ROOSE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1524 PINTO LN FL 3
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4195
Mailing Address - Country:US
Mailing Address - Phone:702-780-7588
Mailing Address - Fax:
Practice Address - Street 1:3900 CAMBRIDGE ST STE 102
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-7440
Practice Address - Country:US
Practice Address - Phone:702-307-5415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-28
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVDO3473208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics