Provider Demographics
NPI:1194296327
Name:ROACH, COURTNEY ANNE (PA-C)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:ANNE
Last Name:ROACH
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 1:450 N GRAHAM ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1682
Mailing Address - Country:US
Mailing Address - Phone:503-413-4488
Mailing Address - Fax:
Practice Address - Street 1:2200 NE NEFF RD STE 200
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4281
Practice Address - Country:US
Practice Address - Phone:541-382-3344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORPA194379363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program