Healthcare Provider Details

I. General information

NPI: 1689758302
Provider Name (Legal Business Name): SUSAN L. ROSE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 09/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 16TH AVE STE 100
SEATTLE WA
98122-5636
US

IV. Provider business mailing address

PO BOX 34400
SEATTLE WA
98124-1400
US

V. Phone/Fax

Practice location:
  • Phone: 206-320-2484
  • Fax: 206-320-4568
Mailing address:
  • Phone: 206-320-2484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPA10001719
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: