Provider Demographics
NPI:1992949531
Name:ROSE, AMY MICHELLE (PA-C)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:MICHELLE
Last Name:ROSE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:MICHELLE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:633 EMERSON RD STE 10
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6739
Mailing Address - Country:US
Mailing Address - Phone:314-991-2150
Mailing Address - Fax:314-991-2149
Practice Address - Street 1:633 EMERSON RD STE 10
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-6739
Practice Address - Country:US
Practice Address - Phone:314-991-2150
Practice Address - Fax:314-991-2149
Is Sole Proprietor?:No
Enumeration Date:2009-04-27
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009009277363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant