Provider Demographics
NPI:1750667200
Name:ROA, BRIAN (RN)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:ROA
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7175 CROSSWATER CT
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89523-7104
Mailing Address - Country:US
Mailing Address - Phone:980-328-2067
Mailing Address - Fax:
Practice Address - Street 1:975 KIRMAN AVE
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-0993
Practice Address - Country:US
Practice Address - Phone:775-786-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-28
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC204556163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse