Healthcare Provider Details

I. General information

NPI: 1629003736
Provider Name (Legal Business Name): ANTHONY JOSEPH ROSE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 12/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 WEST ERIE
HARRISON AR
72601
US

IV. Provider business mailing address

224 W ERIE AVE
HARRISON AR
72601-3539
US

V. Phone/Fax

Practice location:
  • Phone: 870-741-8289
  • Fax: 870-741-0308
Mailing address:
  • Phone: 870-741-8289
  • Fax: 870-741-0308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085002770
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number92PA15
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA-421
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: