Provider Demographics
NPI:1093739872
Name:ROQUEMORE, SANDEE W (PA-C)
Entity Type:Individual
Prefix:
First Name:SANDEE
Middle Name:W
Last Name:ROQUEMORE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1263
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:TX
Mailing Address - Zip Code:77539-1263
Mailing Address - Country:US
Mailing Address - Phone:409-933-0733
Mailing Address - Fax:409-933-9777
Practice Address - Street 1:622 HIGHWAY 3
Practice Address - Street 2:
Practice Address - City:LA MARQUE
Practice Address - State:TX
Practice Address - Zip Code:77568-5936
Practice Address - Country:US
Practice Address - Phone:409-933-0733
Practice Address - Fax:409-933-9777
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00422363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0053KDOtherBLUE CROSS BLUE SHIELD
TX080803201Medicaid
TXDA0825OtherMEDICARE RAILROAD
TXDA0825OtherMEDICARE RAILROAD
TXP62645Medicare UPIN
TX680552086OtherEIN NUMBER