Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0210X | Pediatric Nephrologist | 54320 | WI |
NPI | 1003930553 |
---|---|
Provider Name | Dr. Jesse Roach |
First Address | Middleton, WI 53562-5531 |
Second Address | Madison, WI 53792-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/03/2007 |
Last Update Date | 14/06/2010 |