Provider Demographics
NPI:1750106951
Name:ROACH, REAGAN (APRN)
Entity type:Individual
Prefix:
First Name:REAGAN
Middle Name:
Last Name:ROACH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:377 MORGAN AVE
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TX
Mailing Address - Zip Code:75462-2540
Mailing Address - Country:US
Mailing Address - Phone:903-517-8201
Mailing Address - Fax:
Practice Address - Street 1:107 MEDICAL CIR
Practice Address - Street 2:
Practice Address - City:SULPHUR SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75482-2138
Practice Address - Country:US
Practice Address - Phone:903-885-1770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-21
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1179532363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health