Provider Demographics
NPI:1457245276
Name:ROACH, AUSTIN JEFFREY (DNP, CRNA)
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:JEFFREY
Last Name:ROACH
Suffix:
Gender:M
Credentials:DNP, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 EASTSIDE RD
Mailing Address - Street 2:
Mailing Address - City:PLATTEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53818-9800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 EASTSIDE RD
Practice Address - Street 2:
Practice Address - City:PLATTEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53818-9800
Practice Address - Country:US
Practice Address - Phone:608-348-2331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-05
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24951030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse