Provider Demographics
NPI:1912690579
Name:ROETKEN, REGAN
Entity type:Individual
Prefix:
First Name:REGAN
Middle Name:
Last Name:ROETKEN
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 1:106 S STATE ROAD 135 STE C
Mailing Address - Street 2:
Mailing Address - City:TRAFALGAR
Mailing Address - State:IN
Mailing Address - Zip Code:46181-8702
Mailing Address - Country:US
Mailing Address - Phone:317-878-4972
Mailing Address - Fax:317-878-4593
Practice Address - Street 1:106 SR-135
Practice Address - Street 2:UNIT C
Practice Address - City:TRAFALGAR
Practice Address - State:IN
Practice Address - Zip Code:46181
Practice Address - Country:US
Practice Address - Phone:317-878-4972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant