Provider Demographics
NPI:1588283451
Name:ROLAND, MEGAN RAE
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:RAE
Last Name:ROLAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1847 W HEATHERBRAE DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-4764
Mailing Address - Country:US
Mailing Address - Phone:602-274-2100
Mailing Address - Fax:602-535-3166
Practice Address - Street 1:5140 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-7915
Practice Address - Country:US
Practice Address - Phone:602-207-8400
Practice Address - Fax:480-588-2855
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-10
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ390200000X390200000X
AZ8088363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ8088OtherSTATE LICENSE