Provider Demographics
NPI:1912693771
Name:ROSE, RAVEN (PA)
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:ROSE
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 1:5798 OGEECHEE RD APT 833
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-9542
Mailing Address - Country:US
Mailing Address - Phone:404-645-4993
Mailing Address - Fax:
Practice Address - Street 1:4150 DEPUTY BILL CANTRELL MEMORIAL RD
Practice Address - Street 2:SUITE #290
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040
Practice Address - Country:US
Practice Address - Phone:470-719-1578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-14
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant