Provider Demographics
NPI:1780627885
Name:ROSE, SCOTTY R (PA)
Entity type:Individual
Prefix:
First Name:SCOTTY
Middle Name:R
Last Name:ROSE
Suffix:
Gender:M
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 634715
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 S EISENHOWER DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-4929
Practice Address - Country:US
Practice Address - Phone:304-256-7100
Practice Address - Fax:304-256-7111
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV624363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1780627885Medicaid
WVROPA26171Medicare PIN
WVPENDINGMedicaid