Provider Demographics
NPI:1619967478
Name:ROACH, ARTHUR THOMAS (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ARTHUR
Middle Name:THOMAS
Last Name:ROACH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5185 NAIL ROAD
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-8245
Mailing Address - Country:US
Mailing Address - Phone:662-895-6738
Mailing Address - Fax:662-280-1736
Practice Address - Street 1:3040 GOODMAN ROAD, SUITE C
Practice Address - Street 2:
Practice Address - City:HORN LAKE
Practice Address - State:MS
Practice Address - Zip Code:38637-1189
Practice Address - Country:US
Practice Address - Phone:662-280-3428
Practice Address - Fax:662-280-1736
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA-025363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical