Provider Demographics
NPI:1750751467
Name:ROSE, JEREMY
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:ROSE
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 1:17 LANSING ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-1983
Mailing Address - Country:US
Mailing Address - Phone:315-567-0455
Mailing Address - Fax:315-253-1795
Practice Address - Street 1:77 NELSON ST
Practice Address - Street 2:SUITE 120
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-1944
Practice Address - Country:US
Practice Address - Phone:315-252-7559
Practice Address - Fax:315-253-8104
Is Sole Proprietor?:No
Enumeration Date:2015-10-07
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019192-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant