Provider Demographics
NPI:1497702500
Name:ROLLER, ALFRED S (MD)
Entity Type:Individual
Prefix:
First Name:ALFRED
Middle Name:S
Last Name:ROLLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:505 S 336TH ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6328
Mailing Address - Country:US
Mailing Address - Phone:253-838-6180
Mailing Address - Fax:253-838-6418
Practice Address - Street 1:801 E WHEELER RD
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-1820
Practice Address - Country:US
Practice Address - Phone:509-766-1301
Practice Address - Fax:509-766-1306
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00020773207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0228471OtherLIWA
WA2655ROOtherBSWA
WA3076ROOtherBSWA
WA1131200Medicaid
WAGAB29129Medicare PIN
WA2655ROOtherBSWA
WAG63079Medicare UPIN
WAG8903685Medicare PIN
WA1131200Medicaid