Provider Demographics
NPI:1245636190
Name:ROSE, JAMES (AGCNS-BC)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:
Last Name:ROSE
Suffix:
Gender:M
Credentials:AGCNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 LARK ST
Mailing Address - Street 2:
Mailing Address - City:LEANDER
Mailing Address - State:TX
Mailing Address - Zip Code:78641-1750
Mailing Address - Country:US
Mailing Address - Phone:512-468-2339
Mailing Address - Fax:
Practice Address - Street 1:1924 FOREST RIDGE DR
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-8228
Practice Address - Country:US
Practice Address - Phone:817-545-4550
Practice Address - Fax:817-571-0804
Is Sole Proprietor?:No
Enumeration Date:2014-11-05
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP126386364SA2200X, 364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
No364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX431836YKPWMedicare PIN