Provider Demographics
NPI:1215021415
Name:ROACH, MILDRED (PA)
Entity Type:Individual
Prefix:
First Name:MILDRED
Middle Name:
Last Name:ROACH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2950 ROBERTSON AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45209-1268
Mailing Address - Country:US
Mailing Address - Phone:513-281-4400
Mailing Address - Fax:513-587-8213
Practice Address - Street 1:1 WYOMING ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2722
Practice Address - Country:US
Practice Address - Phone:513-281-4400
Practice Address - Fax:513-587-8213
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-000953363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant