Provider Demographics
NPI:1790724144
Name:ROCHE, ELIZABETH (PA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:ROCHE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13685 DOCTORS WAY
Practice Address - Street 2:SUITE 310
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4336
Practice Address - Country:US
Practice Address - Phone:239-343-1400
Practice Address - Fax:239-343-1430
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC01449363A00000X
FLPA9106092363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS61991Medicare UPIN
MDK727764VMedicare PIN