Provider Demographics
NPI:1669054698
Name:ROSE, MATTHEW W (CAPS)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:W
Last Name:ROSE
Suffix:
Gender:M
Credentials:CAPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1538 MARY DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-1946
Mailing Address - Country:US
Mailing Address - Phone:814-792-4389
Mailing Address - Fax:
Practice Address - Street 1:1538 MARY DR
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905-1946
Practice Address - Country:US
Practice Address - Phone:814-792-4389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPA155628171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications