Healthcare Provider Details

I. General information

NPI: 1184101073
Provider Name (Legal Business Name): LUKE ROSEN, DO, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2018
Last Update Date: 09/30/2022
Certification Date: 09/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1174 ALTURAS DR UNIT 4B
MOSCOW ID
83843-8341
US

IV. Provider business mailing address

1174 ALTURAS DR UNIT 4B
MOSCOW ID
83843-8341
US

V. Phone/Fax

Practice location:
  • Phone: 360-828-8130
  • Fax: 360-785-2171
Mailing address:
  • Phone: 360-828-8130
  • Fax: 360-785-2171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberOP60447877
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberOP60447877
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: LUKE BILLMEYER ROSEN
Title or Position: OWNER
Credential: DO
Phone: 360-828-8130