Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LA2200X | Nurse Practitioner - Adult Health | SP021669 | PA |
N | 363LF0000X | Nurse Practitioner - Family Medicine | APRN11004127 | FL |
N | 363LF0000X | Nurse Practitioner - Family Medicine | SP021669 | PA |
NPI | 1023425600 |
---|---|
Provider Name | Gavin Roache |
First Address | Harrisburg, PA 17101-2010 |
Second Address | Harrisburg, PA 17101-2010 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/07/2014 |
Last Update Date | 16/04/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
016388100 | (05) | FL |