Provider Demographics
NPI:1184609034
Name:ROSE, MARTIN PHILLIP (PA)
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:PHILLIP
Last Name:ROSE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4841 SEVEN TRAILS CIR
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:MD
Mailing Address - Zip Code:21001-2628
Mailing Address - Country:US
Mailing Address - Phone:410-278-5356
Mailing Address - Fax:
Practice Address - Street 1:2501 OAKINGTON ST
Practice Address - Street 2:
Practice Address - City:APG
Practice Address - State:MD
Practice Address - Zip Code:21005-5131
Practice Address - Country:US
Practice Address - Phone:410-278-5356
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1042882363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical