Provider Demographics
NPI:1659444685
Name:ROACH, TERRY R (CRNA)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:R
Last Name:ROACH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1218 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2828
Mailing Address - Country:US
Mailing Address - Phone:719-543-7877
Mailing Address - Fax:719-543-7882
Practice Address - Street 1:1218 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2828
Practice Address - Country:US
Practice Address - Phone:719-543-7877
Practice Address - Fax:719-543-7882
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO92845367500000X
CO92846367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered