Provider Demographics
NPI:1427193598
Name:ROARK, CONSTANCE (FNP)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:
Last Name:ROARK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MERCADO ST
Mailing Address - Street 2:STE 160
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-7306
Mailing Address - Country:US
Mailing Address - Phone:970-385-9850
Mailing Address - Fax:970-385-9854
Practice Address - Street 1:1 MERCADO ST
Practice Address - Street 2:STE 160
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7306
Practice Address - Country:US
Practice Address - Phone:970-385-9850
Practice Address - Fax:970-385-9854
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX685472363LF0000X
COAPN.0993032363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX87N474Medicare ID - Type Unspecified
TX87N475Medicare ID - Type Unspecified
TXP57518Medicare UPIN
TX87N493Medicare ID - Type Unspecified