Provider Demographics
NPI:1063599785
Name:ROCCO, KATHLEEN R (PA - C)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:R
Last Name:ROCCO
Suffix:
Gender:F
Credentials:PA - C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 E 32ND ST
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-7287
Mailing Address - Country:US
Mailing Address - Phone:575-538-2981
Mailing Address - Fax:575-388-3373
Practice Address - Street 1:5933 NE WIN SIVERS DR STE 305
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-9106
Practice Address - Country:US
Practice Address - Phone:503-420-5852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA20080030363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM01676860Medicaid
NM300711Medicare PIN