Provider Demographics
NPI:1225531635
Name:ACHURI, ROOPA
Entity Type:Individual
Prefix:
First Name:ROOPA
Middle Name:
Last Name:ACHURI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 E COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-5794
Mailing Address - Country:US
Mailing Address - Phone:920-996-3264
Mailing Address - Fax:920-830-5910
Practice Address - Street 1:200 THEDA CLARK MEDICAL PLZ STE 240
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2790
Practice Address - Country:US
Practice Address - Phone:920-831-5050
Practice Address - Fax:920-727-4511
Is Sole Proprietor?:No
Enumeration Date:2018-03-12
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3501363A00000X
WI4318363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant