Healthcare Provider Details

I. General information

NPI: 1700849395
Provider Name (Legal Business Name): LAWRENCE HAYES ROSE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 03/08/2021
Certification Date: 03/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 NE MOTHER JOSEPH PL
VANCOUVER WA
98664-3200
US

IV. Provider business mailing address

19020 33RD AVE W STE 210
LYNNWOOD WA
98036-4748
US

V. Phone/Fax

Practice location:
  • Phone: 360-892-9664
  • Fax: 360-892-9667
Mailing address:
  • Phone: 425-563-1500
  • Fax: 425-563-1501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD00044499
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberMD00044499
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: