1184795346 NPI number — MR. GEORGE NORMAN ROLL PA-C

Table of content: MR. GEORGE NORMAN ROLL PA-C (NPI 1184795346)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184795346 NPI number — MR. GEORGE NORMAN ROLL PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROLL
Provider First Name:
GEORGE
Provider Middle Name:
NORMAN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

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:
1184795346
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5399 E COUNTY HIGHWAY 30A
Provider Second Line Business Mailing Address:
SUITE 5
Provider Business Mailing Address City Name:
SANTA ROSA BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32459-6717
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-231-6200
Provider Business Mailing Address Fax Number:
850-231-3500

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5399 EAST COUNTY HIGHWAY 30A
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
SANTA ROSA BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32459-6718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-231-6200
Provider Business Practice Location Address Fax Number:
850-231-3500
Provider Enumeration Date:
11/10/2006

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:  PA31941FL , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 290446200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com