Provider Demographics
NPI:1982791414
Name:RADER, ROSE (PA)
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:RADER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ANN-MARIE
Other - Middle Name:
Other - Last Name:RADER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:110 EXECUTIVE PARK WAY
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-3930
Mailing Address - Country:US
Mailing Address - Phone:843-899-9099
Mailing Address - Fax:843-899-9091
Practice Address - Street 1:110 EXECUTIVE PARK WAY
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-3930
Practice Address - Country:US
Practice Address - Phone:843-899-9099
Practice Address - Fax:843-899-9091
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1147363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0458PAMedicaid
SC0458PAMedicaid
SCAA15548479Medicare PIN