Healthcare Provider Details

I. General information

NPI: 1073998225
Provider Name (Legal Business Name): MR. LANNY ROSE JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2015
Last Update Date: 07/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

536 BROKER HILL ROAD
BECKET MA
01223
US

IV. Provider business mailing address

PO BOX 412
BECKET MA
01223-0412
US

V. Phone/Fax

Practice location:
  • Phone: 413-770-2928
  • Fax:
Mailing address:
  • Phone: 413-770-2928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9098
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: