Provider Demographics
NPI:1609242502
Name:ROACH, SEAN I
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:ROACH
Suffix:I
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 1:2 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:MILLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:12545-5948
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 FRONT ST
Practice Address - Street 2:
Practice Address - City:MILLBROOK
Practice Address - State:NY
Practice Address - Zip Code:12545-5948
Practice Address - Country:US
Practice Address - Phone:845-677-5021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-13
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002872246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other