Provider Demographics
NPI:1437232097
Name:ROACH, RONALD (CRNA)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:ROACH
Suffix:
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 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1562
Mailing Address - Country:US
Mailing Address - Phone:740-441-1949
Mailing Address - Fax:740-446-5982
Practice Address - Street 1:100 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631
Practice Address - Country:US
Practice Address - Phone:855-446-5937
Practice Address - Fax:740-446-5486
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CRNA.019706367500000X
WV73573367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810004370Medicaid
WVP00275516OtherR MEDICARE
WVRO7339891Medicare ID - Type Unspecified