Provider Demographics
NPI:1639678451
Name:ROSER, ALLYSON LEIGH (PA)
Entity Type:Individual
Prefix:
First Name:ALLYSON
Middle Name:LEIGH
Last Name:ROSER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ALLYSON
Other - Middle Name:LEIGH
Other - Last Name:PELUDAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:4600 MEMORIAL DR STE W3
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5359
Mailing Address - Country:US
Mailing Address - Phone:618-222-8900
Mailing Address - Fax:618-416-4449
Practice Address - Street 1:4600 MEMORIAL DR STE W3
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5359
Practice Address - Country:US
Practice Address - Phone:618-222-8900
Practice Address - Fax:618-416-4449
Is Sole Proprietor?:No
Enumeration Date:2018-02-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.006541363A00000X
MA1150728363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical