Provider Demographics
NPI:1306807953
Name:ROFF, ALISHA JILLY (PA)
Entity type:Individual
Prefix:MR
First Name:ALISHA
Middle Name:JILLY
Last Name:ROFF
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:ALLAN
Other - Middle Name:JAY
Other - Last Name:ROFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:304 S. 22ND STREET
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76501
Mailing Address - Country:US
Mailing Address - Phone:254-298-7041
Mailing Address - Fax:
Practice Address - Street 1:304 S. 22ND STREET
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76501
Practice Address - Country:US
Practice Address - Phone:254-298-7041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02772363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX096692101Medicaid
TX85N695Medicare ID - Type UnspecifiedPERFORMING PROVIDER NUMBE