Provider Demographics
NPI:1487706859
Name:ROSE, RITA JEAN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:RITA
Middle Name:JEAN
Last Name:ROSE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2104 E. 11 MILE ROAD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48091
Mailing Address - Country:US
Mailing Address - Phone:586-758-6222
Mailing Address - Fax:586-758-6232
Practice Address - Street 1:2104 E. 11 MILE ROAD
Practice Address - Street 2:SUITE 600
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091
Practice Address - Country:US
Practice Address - Phone:586-758-6222
Practice Address - Fax:586-758-6232
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003424363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP68505Medicare UPIN
MI0N55450Medicare ID - Type Unspecified