Healthcare Provider Details

I. General information

NPI: 1497553747
Provider Name (Legal Business Name): ISIAH BLAKE ROSALES PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2025
Last Update Date: 03/16/2026
Certification Date: 03/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8214 MILWAUKEE AVE STE 200
LUBBOCK TX
79424-0959
US

IV. Provider business mailing address

5219 CITY BANK PKWY STE 35
LUBBOCK TX
79407-3545
US

V. Phone/Fax

Practice location:
  • Phone: 806-475-5544
  • Fax:
Mailing address:
  • Phone: 806-775-9700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA19041
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: