Provider Demographics
NPI:1063523454
Name:ROSE, VADA ALBERTA (NP)
Entity type:Individual
Prefix:
First Name:VADA
Middle Name:ALBERTA
Last Name:ROSE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1490 PARK AVE NW
Mailing Address - Street 2:SUITE 3
Mailing Address - City:NORTON
Mailing Address - State:VA
Mailing Address - Zip Code:24273-1631
Mailing Address - Country:US
Mailing Address - Phone:276-679-8890
Mailing Address - Fax:276-679-9740
Practice Address - Street 1:1490 PARK AVE NW
Practice Address - Street 2:SUITE 3
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273-1631
Practice Address - Country:US
Practice Address - Phone:276-679-8890
Practice Address - Fax:276-679-9740
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166719363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1063523454Medicaid
KY7100127160Medicaid
VAP00686108OtherRAILROAD MEDICARE
VA00X674N19Medicare PIN
KY7100127160Medicaid