Provider Demographics
NPI:1053655324
Name:ROAQUIN, RAOUL J (PT)
Entity Type:Individual
Prefix:MR
First Name:RAOUL
Middle Name:J
Last Name:ROAQUIN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1831 SHORES RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-4313
Mailing Address - Country:US
Mailing Address - Phone:404-513-9051
Mailing Address - Fax:
Practice Address - Street 1:1833 CLIFTON RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-4021
Practice Address - Country:US
Practice Address - Phone:404-728-6528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT007612225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist