Provider Demographics
NPI:1770549396
Name:BACKS, ROSE A (PA)
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:A
Last Name:BACKS
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 1:2050 KENNY RD
Mailing Address - Street 2:STE 3100
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43221-3502
Mailing Address - Country:US
Mailing Address - Phone:614-293-3693
Mailing Address - Fax:
Practice Address - Street 1:2050 KENNY RD STE 3100
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43221-3502
Practice Address - Country:US
Practice Address - Phone:614-293-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1857363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHBAPA19512Medicare PIN