1205206174 NPI number — MRS. CHRISTINE DENISON ROE NP

Table of content: MRS. CHRISTINE DENISON ROE NP (NPI 1205206174)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205206174 NPI number — MRS. CHRISTINE DENISON ROE NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROE
Provider First Name:
CHRISTINE
Provider Middle Name:
DENISON
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205206174
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
449 ROUTE 146 STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HALFMOON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12065-3239
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-373-3924
Provider Business Mailing Address Fax Number:
518-373-3808

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 CROSSINGS BLVD
Provider Second Line Business Practice Location Address:
SUITE ONE
Provider Business Practice Location Address City Name:
CLIFTON PARK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12065
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-831-4434
Provider Business Practice Location Address Fax Number:
518-831-4439
Provider Enumeration Date:
10/04/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  AP60565547 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 338753 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1205206174 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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