Provider Demographics
NPI:1851950364
Name:ROACH, JUSTIN T (APRN, NP-C)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:T
Last Name:ROACH
Suffix:
Gender:
Credentials:APRN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3015 N MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762-2546
Mailing Address - Country:US
Mailing Address - Phone:620-240-5607
Mailing Address - Fax:
Practice Address - Street 1:204 S MAIN ST
Practice Address - Street 2:
Practice Address - City:YATES CENTER
Practice Address - State:KS
Practice Address - Zip Code:66783-1444
Practice Address - Country:US
Practice Address - Phone:620-625-2746
Practice Address - Fax:888-802-7094
Is Sole Proprietor?:No
Enumeration Date:2019-06-08
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-78756-082363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily