Provider Demographics
NPI:1487877619
Name:ROSE, AUDRA J (PA)
Entity type:Individual
Prefix:
First Name:AUDRA
Middle Name:J
Last Name:ROSE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AUDRA
Other - Middle Name:J
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3450 POTOMAC WAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-4970
Mailing Address - Country:US
Mailing Address - Phone:208-557-2900
Mailing Address - Fax:208-557-2910
Practice Address - Street 1:3450 POTOMAC WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7407
Practice Address - Country:US
Practice Address - Phone:208-557-2900
Practice Address - Fax:208-557-2910
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYTL403363A00000X
IDM6628207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807761500Medicaid
ID807761500Medicaid