Basic Information
| Provider Information | |||||||||
| NPI: | 1700927613 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSE | ||||||||
| FirstName: | WALTER | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29 REEMS TRACE RD | ||||||||
| Address2: | |||||||||
| City: | WEAVERVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287878414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286455294 | ||||||||
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| Practice Location | |||||||||
| Address1: | 445 BILTMORE AVE | ||||||||
| Address2: | 407 | ||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288014565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282580397 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 07/08/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 103502 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 103502 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 103502 | 01 | NC | LICENSE | OTHER |