Provider Demographics
NPI:1346200896
Name:ROACH, KRISTINA O (PA)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:O
Last Name:ROACH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:R
Other - Last Name:OMPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:220 CAMPUS BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-2896
Mailing Address - Country:US
Mailing Address - Phone:540-536-5100
Mailing Address - Fax:540-536-0235
Practice Address - Street 1:1870 AMHERST ST STE 2B
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-2841
Practice Address - Country:US
Practice Address - Phone:540-536-2790
Practice Address - Fax:540-536-2791
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840646363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007008S71OtherMEDICARE PIN (OLD)
VA1346200896Medicaid
VAP00734696OtherMEDICARE RR
VAMC10688Medicare PIN
S25255Medicare UPIN