Provider Demographics
NPI:1740326495
Name:ROSE, CARL WARREN (PA-C)
Entity type:Individual
Prefix:MR
First Name:CARL
Middle Name:WARREN
Last Name:ROSE
Suffix:
Gender:M
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:PO BOX 595
Mailing Address - Street 2:
Mailing Address - City:WESTMORELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37186-0595
Mailing Address - Country:US
Mailing Address - Phone:615-644-3000
Mailing Address - Fax:615-644-3076
Practice Address - Street 1:12124 HIGHWAY 52 W STE 5
Practice Address - Street 2:
Practice Address - City:WESTMORELAND
Practice Address - State:TN
Practice Address - Zip Code:37186-3257
Practice Address - Country:US
Practice Address - Phone:615-644-3000
Practice Address - Fax:615-644-3076
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA265363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3373426Medicaid
TN4019704OtherBLUE CROSS BLUE SHIELD
TN4019704OtherBLUE CROSS BLUE SHIELD
TN3373426Medicaid