Healthcare Provider Details

I. General information

NPI: 1023628898
Provider Name (Legal Business Name): GARY L. ROSE DNP, FNP, ENP, APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2020
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 ASHLEY HALL RD APT E2
CHARLESTON SC
29407-3815
US

IV. Provider business mailing address

1755 ASHLEY HALL RD APT E2
CHARLESTON SC
29407-3815
US

V. Phone/Fax

Practice location:
  • Phone: 843-693-8385
  • Fax:
Mailing address:
  • Phone: 843-693-8385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number00007961-A
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: