Provider Demographics
NPI:1558193797
Name:ROA, WILBUR JR (RN)
Entity type:Individual
Prefix:MR
First Name:WILBUR
Middle Name:
Last Name:ROA
Suffix:JR
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 1:11101 W AIRPORT BLVD APT 8313
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477-3186
Mailing Address - Country:US
Mailing Address - Phone:832-766-5960
Mailing Address - Fax:
Practice Address - Street 1:5373 W ALABAMA ST STE 454
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77056-5947
Practice Address - Country:US
Practice Address - Phone:866-646-6352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-16
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX845165163WW0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WW0000XNursing Service ProvidersRegistered NurseWound Care