Provider Demographics
NPI:1558531921
Name:ROULIER, RACHELLE MARIE (PA)
Entity Type:Individual
Prefix:
First Name:RACHELLE
Middle Name:MARIE
Last Name:ROULIER
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 1:8385 DIVISION RD
Mailing Address - Street 2:
Mailing Address - City:WHITE CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97503-1176
Mailing Address - Country:US
Mailing Address - Phone:541-842-7626
Mailing Address - Fax:541-842-7640
Practice Address - Street 1:19 MYRTLE ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7337
Practice Address - Country:US
Practice Address - Phone:541-773-3863
Practice Address - Fax:541-776-2892
Is Sole Proprietor?:No
Enumeration Date:2008-03-02
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19601363AM0700X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227698Medicaid