Healthcare Provider Details

I. General information

NPI: 1003989872
Provider Name (Legal Business Name): JANE C ROSEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14547 VICTORY BLVD
VAN NUYS CA
91411-1619
US

IV. Provider business mailing address

29085 OAK CREEK LN APT 701
AGOURA HILLS CA
91301-6433
US

V. Phone/Fax

Practice location:
  • Phone: 818-997-3232
  • Fax:
Mailing address:
  • Phone: 410-456-7622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number64950
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0000595
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: