Provider Demographics
NPI:1083439574
Name:ROACH, BRIAN JAMES (NP)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:JAMES
Last Name:ROACH
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 GREENE ST UNIT 3
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-6968
Mailing Address - Country:US
Mailing Address - Phone:510-566-1920
Mailing Address - Fax:
Practice Address - Street 1:329 GREENE ST UNIT 3
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-6968
Practice Address - Country:US
Practice Address - Phone:510-566-1920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT14174363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily