Provider Demographics
NPI:1225834922
Name:ROARK, ADDISON (PA)
Entity type:Individual
Prefix:
First Name:ADDISON
Middle Name:
Last Name:ROARK
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4209 N REDBUD PL
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-0453
Mailing Address - Country:US
Mailing Address - Phone:918-978-8367
Mailing Address - Fax:
Practice Address - Street 1:12902 E 51ST ST STE 3
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74134-6712
Practice Address - Country:US
Practice Address - Phone:918-994-3482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-22
Last Update Date:2025-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5471363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant