Provider Demographics
NPI:1063650620
Name:ROERING, MARIA JANG (RN)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:JANG
Last Name:ROERING
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOX 57, 75TH MED (AS)
Mailing Address - Street 2:UNIT # 15190
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96271-5160
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:75TH MED (AS)
Practice Address - Street 2:BOX 57 UNIT# 15190
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96271-5160
Practice Address - Country:US
Practice Address - Phone:505-763-8111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-04
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO145447163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN$$$$$$$$$Medicaid