Provider Demographics
NPI:1174086664
Name:ROOSE, JOSHUA
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:ROOSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 W CHARLESTON BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102
Mailing Address - Country:US
Mailing Address - Phone:702-383-2000
Mailing Address - Fax:
Practice Address - Street 1:11860 SOUTHERN HIGHLANDS PKWY STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89141-3304
Practice Address - Country:US
Practice Address - Phone:702-383-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-11
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVDO3474207Q00000X
NVFR3405950207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine