Provider Demographics
NPI:1720649619
Name:ROA, ALEC DANIEL
Entity Type:Individual
Prefix:
First Name:ALEC
Middle Name:DANIEL
Last Name:ROA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 CAMARITAS AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-3156
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2600 S EL CAMINO REAL STE 200
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-2382
Practice Address - Country:US
Practice Address - Phone:650-372-4080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-22
Last Update Date:2019-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA08745596OtherKAISER