Provider Demographics
NPI:1952091480
Name:ROSHAK, TYLER
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:ROSHAK
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 1:2307 RIVER RD STE 101
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-5000
Mailing Address - Country:US
Mailing Address - Phone:502-583-6647
Mailing Address - Fax:
Practice Address - Street 1:2307 RIVER RD STE 101
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40206-5000
Practice Address - Country:US
Practice Address - Phone:502-451-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-09
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant