Healthcare Provider Details

I. General information

NPI: 1750751467
Provider Name (Legal Business Name): JEREMY ROSE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2015
Last Update Date: 10/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 NELSON ST SUITE 120
AUBURN NY
13021-1944
US

IV. Provider business mailing address

17 LANSING ST
AUBURN NY
13021-1983
US

V. Phone/Fax

Practice location:
  • Phone: 315-252-7559
  • Fax: 315-253-8104
Mailing address:
  • Phone: 315-567-0455
  • Fax: 315-253-1795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number019192-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: