1538160593 NPI number — ROXANNE MONGEON PA

Table of content: ROXANNE MONGEON PA (NPI 1538160593)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538160593 NPI number — ROXANNE MONGEON PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MONGEON
Provider First Name:
ROXANNE
Provider Middle Name:
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:
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:
1538160593
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2801 REGAL RD
Provider Second Line Business Mailing Address:
SUITE 108
Provider Business Mailing Address City Name:
PLANO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75075-6315
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-599-0080
Provider Business Mailing Address Fax Number:
972-599-0082

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2801 REGAL RD
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
PLANO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75075-6315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-599-0080
Provider Business Practice Location Address Fax Number:
972-599-0082
Provider Enumeration Date:
08/02/2005

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: 363AS0400X , with the licence number:  000037 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: PA10537 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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