Provider Demographics
NPI:1326061235
Name:ROACH, LEASA L (GNP)
Entity Type:Individual
Prefix:
First Name:LEASA
Middle Name:L
Last Name:ROACH
Suffix:
Gender:F
Credentials:GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 E 35TH ST
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-2746
Mailing Address - Country:US
Mailing Address - Phone:903-835-5355
Mailing Address - Fax:903-735-5399
Practice Address - Street 1:1205 E 35TH ST
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-2746
Practice Address - Country:US
Practice Address - Phone:903-735-5355
Practice Address - Fax:903-735-5399
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX526631363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX526631OtherLICENSE
AR163821758Medicaid
TX8Y1726OtherBLUE CROSS BLUE SHIELD
AR5A158OtherBLUECROSS BLUESHIELD
TXP00376988OtherRAILROAD MEDICARE
TXP00376988OtherRAILROAD MEDICARE