Provider Demographics
NPI:1255341459
Name:ROSE, ROBIN (PA-C)
Entity type:Individual
Prefix:
First Name:ROBIN
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-1806
Mailing Address - Country:US
Mailing Address - Phone:203-234-3977
Mailing Address - Fax:
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:5-4 SP
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-688-1952
Practice Address - Fax:203-688-2394
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001625363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical