Healthcare Provider Details

I. General information

NPI: 1457851404
Provider Name (Legal Business Name): SARA M ROSE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SARA M EYLER PA

II. Dates (important events)

Enumeration Date: 02/16/2018
Last Update Date: 10/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 HOSPITAL DR STE A
LEBANON MO
65536
US

IV. Provider business mailing address

331 HOSPITAL DR STE A
LEBANON MO
65536-9251
US

V. Phone/Fax

Practice location:
  • Phone: 417-533-6560
  • Fax:
Mailing address:
  • Phone: 417-533-6560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2018005544
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: