1346200896 NPI number — KRISTINA O ROACH PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346200896 NPI number — KRISTINA O ROACH PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROACH
Provider First Name:
KRISTINA
Provider Middle Name:
O
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
OMPS
Provider Other First Name:
KRISTINA
Provider Other Middle Name:
R
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1346200896
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/25/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
220 CAMPUS BLVD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINCHESTER
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22601-2896
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-536-5100
Provider Business Mailing Address Fax Number:
540-536-0235

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1870 AMHERST ST STE 2B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINCHESTER
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22601-2841
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-536-2790
Provider Business Practice Location Address Fax Number:
540-536-2791
Provider Enumeration Date:
03/27/2006

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: 363A00000X , with the licence number:  0110840646 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 007008S71 . This is a "MEDICARE PIN (OLD)" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1346200896 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00734696 . This is a "MEDICARE RR" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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