Provider Demographics
NPI:1720814031
Name:ROA, KRYSTAL VICTORIA
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:VICTORIA
Last Name:ROA
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 1:4307 FOOTHILL WAY
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:94565-6208
Mailing Address - Country:US
Mailing Address - Phone:925-852-4976
Mailing Address - Fax:
Practice Address - Street 1:2828 FORD ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-2114
Practice Address - Country:US
Practice Address - Phone:510-268-3770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-12
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker