Healthcare Provider Details

I. General information

NPI: 1902360670
Provider Name (Legal Business Name): BRANDON C ROOSE APRN, FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2019
Last Update Date: 06/30/2022
Certification Date: 06/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9975 W OTTAWA RVE.
EMPIRE MI
49630
US

IV. Provider business mailing address

224 PARK AVE
FRANKFORT MI
49635-9658
US

V. Phone/Fax

Practice location:
  • Phone: 231-835-2088
  • Fax:
Mailing address:
  • Phone: 231-352-2990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704280333
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: