Provider Demographics
NPI:1457576407
Name:SHORTER, ROSALEE (PA)
Entity Type:Individual
Prefix:
First Name:ROSALEE
Middle Name:
Last Name:SHORTER
Suffix:
Gender:F
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:PO BOX 176
Mailing Address - Street 2:
Mailing Address - City:SAINT REGIS
Mailing Address - State:MT
Mailing Address - Zip Code:59866-0176
Mailing Address - Country:US
Mailing Address - Phone:406-649-7307
Mailing Address - Fax:
Practice Address - Street 1:341 MONTANA HWY 135
Practice Address - Street 2:
Practice Address - City:SAINT REGIS
Practice Address - State:MT
Practice Address - Zip Code:59866-0176
Practice Address - Country:US
Practice Address - Phone:406-649-7307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT36405363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical