Basic Information
| Provider Information | |||||||||
| NPI: | 1649745753 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSEN | ||||||||
| FirstName: | JAMIE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18444 N 25TH AVE STE 310 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850231266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669742673 | ||||||||
| FaxNumber: | 8669392673 | ||||||||
| Practice Location | |||||||||
| Address1: | 14520 W GRANITE VALLEY DR STE 210 | ||||||||
| Address2: | |||||||||
| City: | SUN CITY WEST | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853755855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6697426738 | ||||||||
| FaxNumber: | 8669392673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2018 | ||||||||
| LastUpdateDate: | 06/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 7225 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.