Provider Demographics
NPI:1245503929
Name:ROACH, CHRISTINE D (PA-C)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:D
Last Name:ROACH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 S 1680 W
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-4939
Mailing Address - Country:US
Mailing Address - Phone:801-356-5555
Mailing Address - Fax:801-224-6010
Practice Address - Street 1:1215 S 1680 W
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-4939
Practice Address - Country:US
Practice Address - Phone:801-356-5555
Practice Address - Fax:801-224-6010
Is Sole Proprietor?:No
Enumeration Date:2012-02-11
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8046093-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant