Provider Demographics
NPI:1023628898
Name:ROSE, GARY L (DNP, FNP, ENP, APRN)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
Last Name:ROSE
Suffix:
Gender:M
Credentials:DNP, FNP, ENP, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1755 ASHLEY HALL RD APT E2
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-3815
Mailing Address - Country:US
Mailing Address - Phone:843-693-8385
Mailing Address - Fax:
Practice Address - Street 1:1755 ASHLEY HALL RD APT E2
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-3815
Practice Address - Country:US
Practice Address - Phone:843-693-8385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-05
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA00007961-A207P00000X
SCME007961207Q00000X, 207QA0401X, 363LP2300X, 207LA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction MedicineGroup - Single Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0000007961OtherSAMSA