Provider Demographics
NPI:1306203641
Name:ROE, JOHN ERIC JR (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ERIC
Last Name:ROE
Suffix:JR
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1347 NEVINS STATION RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40342-9759
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1011 OLD HIGHWAY 60
Practice Address - Street 2:
Practice Address - City:HARDINSBURG
Practice Address - State:KY
Practice Address - Zip Code:40143
Practice Address - Country:US
Practice Address - Phone:270-756-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-18
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY700663367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3010062OtherAPRN LICENSE
KY700663OtherCRNA CERTIFICATION