Provider Demographics
NPI:1184795346
Name:ROLL, GEORGE NORMAN (PA-C)
Entity type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:NORMAN
Last Name:ROLL
Suffix:
Gender:M
Credentials:PA-C
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Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:5399 E COUNTY HIGHWAY 30A
Mailing Address - Street 2:SUITE 5
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459-6717
Mailing Address - Country:US
Mailing Address - Phone:850-231-6200
Mailing Address - Fax:850-231-3500
Practice Address - Street 1:5399 EAST COUNTY HIGHWAY 30A
Practice Address - Street 2:SUITE 5
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-6718
Practice Address - Country:US
Practice Address - Phone:850-231-6200
Practice Address - Fax:850-231-3500
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA31941FL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290446200Medicaid
FLS69365Medicare UPIN
FL290446200Medicaid