Provider Demographics
NPI:1518380625
Name:ROARK, MARK (APRN)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ROARK
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 COMMERCIAL DR STE 98
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40744-5200
Mailing Address - Country:US
Mailing Address - Phone:606-878-1219
Mailing Address - Fax:068-771-1956
Practice Address - Street 1:195 COMMERCIAL DR STE 98
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40744-5200
Practice Address - Country:US
Practice Address - Phone:606-878-1219
Practice Address - Fax:606-877-1195
Is Sole Proprietor?:No
Enumeration Date:2014-01-24
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008480363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100294960Medicaid