Healthcare Provider Details

I. General information

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

II. Dates (important events)

Enumeration Date: 03/04/2025
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8214 MILWAUKEE AVE STE 200
LUBBOCK TX
79424-0959
US

IV. Provider business mailing address

1805 W AVENUE H
MULESHOE TX
79347-4329
US

V. Phone/Fax

Practice location:
  • Phone: 806-475-5544
  • Fax:
Mailing address:
  • Phone: 806-773-8834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: