Provider Demographics
NPI:1558315325
Name:FLETCHER, ROCKY J
Entity Type:Individual
Prefix:
First Name:ROCKY
Middle Name:J
Last Name:FLETCHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 W FIRST ST
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387
Mailing Address - Country:US
Mailing Address - Phone:952-442-9770
Mailing Address - Fax:952-442-3620
Practice Address - Street 1:1825 LOGAN AVE
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50703-1999
Practice Address - Country:US
Practice Address - Phone:319-235-3886
Practice Address - Fax:319-233-1630
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAD-058051367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA43339OtherWELLMARK INS PLAN
IA10745OtherMIDLANDS CHOICE
IA2267047Medicaid
IA26585OtherBLUE CROSS OF IA
IA421417307A6OtherJOHN DEERE HEALTH INS
IA10745OtherMIDLANDS CHOICE