Provider Demographics
NPI:1083096663
Name:ROSKOP, CARLY
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:ROSKOP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:Y
Other - Last Name:CHADEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3701 KATZ DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IA
Mailing Address - Zip Code:52302-3871
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:709 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:IA
Practice Address - Zip Code:52057-1526
Practice Address - Country:US
Practice Address - Phone:563-927-3232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-19
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA129749363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily