Provider Demographics
NPI:1710335112
Name:ROACH, PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:ROACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 N KANSAS ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-3124
Mailing Address - Country:US
Mailing Address - Phone:316-268-6147
Mailing Address - Fax:
Practice Address - Street 1:8080 E CENTRAL AVE STE 250
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-2367
Practice Address - Country:US
Practice Address - Phone:316-686-7327
Practice Address - Fax:316-686-1557
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-26
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS94-08894207L00000X
WI2851207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100232824Medicaid