Provider Demographics
NPI:1609597392
Name:ROA, KEVIN (PMHNP)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:ROA
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2775 S JONES BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-5632
Mailing Address - Country:US
Mailing Address - Phone:702-685-3300
Mailing Address - Fax:
Practice Address - Street 1:620 S TONOPAH DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4029
Practice Address - Country:US
Practice Address - Phone:702-413-1391
Practice Address - Fax:702-413-1392
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-09
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8579712084P0800X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1760195796Medicaid