Provider Demographics
NPI:1184160293
Name:ROSE, JUSTIN SCOTT (CRNA)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:SCOTT
Last Name:ROSE
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 1:933 OLD WILDERNESS RD
Mailing Address - Street 2:
Mailing Address - City:SALTVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24370-4229
Mailing Address - Country:US
Mailing Address - Phone:276-782-5757
Mailing Address - Fax:
Practice Address - Street 1:100 15TH ST NW
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273-1616
Practice Address - Country:US
Practice Address - Phone:276-439-1425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-12
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024174579367500000X
VA0001231492163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse