Provider Demographics
NPI:1104918630
Name:ROSA, PETER S (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:S
Last Name:ROSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 UTAH, 2ND FLOOR
Mailing Address - Street 2:
Mailing Address - City:HIAWATHA
Mailing Address - State:KS
Mailing Address - Zip Code:66434-2314
Mailing Address - Country:US
Mailing Address - Phone:785-742-2161
Mailing Address - Fax:785-742-6554
Practice Address - Street 1:300 UTAH, 2ND FLOOR
Practice Address - Street 2:
Practice Address - City:HIAWATHA
Practice Address - State:KS
Practice Address - Zip Code:66434-2314
Practice Address - Country:US
Practice Address - Phone:785-742-2161
Practice Address - Fax:785-742-6554
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0426820207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100315890AMedicaid
KSG47335Medicare UPIN
KS100315890AMedicaid