Basic Information
| Provider Information | |||||||||
| NPI: | 1093364911 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSEN | ||||||||
| FirstName: | WHITNEY | ||||||||
| MiddleName: | RONDELL | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 825 N MAIN ST | ||||||||
| Address2: | STE 140 | ||||||||
| City: | SPRINGBORO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450662100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377625000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 825 N MAIN ST | ||||||||
| Address2: | STE 140 | ||||||||
| City: | SPRINGBORO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450662100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377625000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2019 | ||||||||
| LastUpdateDate: | 08/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 50.006111RX | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 50.006111RX | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 0372406 | 05 | OH | MEDICAID |