Provider Demographics
NPI:1487604948
Name:ROSEBERRY, TY MARTIN (PA)
Entity type:Individual
Prefix:MR
First Name:TY
Middle Name:MARTIN
Last Name:ROSEBERRY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14380 MAIN ST
Mailing Address - Street 2:SUITE 120, PMB 160
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-4613
Mailing Address - Country:US
Mailing Address - Phone:760-947-3220
Mailing Address - Fax:
Practice Address - Street 1:1801 N SENATE BLVD
Practice Address - Street 2:#200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1228
Practice Address - Country:US
Practice Address - Phone:317-802-2000
Practice Address - Fax:317-924-0115
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000768A363A00000X
CA19182363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN037170H4Medicare ID - Type Unspecified
INQ47490Medicare UPIN