Provider Demographics
NPI:1437225596
Name:ROESE, DEBORAH (PA)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:ROESE
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 1:122 DEMAREE DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-4622
Mailing Address - Country:US
Mailing Address - Phone:812-265-9191
Mailing Address - Fax:812-265-1050
Practice Address - Street 1:122 DEMAREE DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-4622
Practice Address - Country:US
Practice Address - Phone:812-265-9191
Practice Address - Fax:812-265-1050
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000793A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
INS54816Medicare UPIN