Provider Demographics
NPI:1639165962
Name:RADICH, ROXANNE D (APNP)
Entity Type:Individual
Prefix:
First Name:ROXANNE
Middle Name:D
Last Name:RADICH
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7543 SUNBURST LN
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-9016
Mailing Address - Country:US
Mailing Address - Phone:920-851-2458
Mailing Address - Fax:
Practice Address - Street 1:3916 N INTERTECH CT
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-6957
Practice Address - Country:US
Practice Address - Phone:920-996-1000
Practice Address - Fax:920-996-1050
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2351-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI401600070Medicare Oscar/Certification
Q02702Medicare UPIN