Basic Information
| Provider Information | |||||||||
| NPI: | 1235102336 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSE | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 MAPLEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | WOLFEBORO | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038944024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034554037 | ||||||||
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| Practice Location | |||||||||
| Address1: | 25A JUNE ST | ||||||||
| Address2: | |||||||||
| City: | SANFORD | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040732642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074907900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2006 | ||||||||
| LastUpdateDate: | 06/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA2196 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 0457 P | NH | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 30332536 | 05 | NH | MEDICAID | 0400503YPNH01 | 01 | NH | ANTHEM | OTHER |