Provider Demographics
NPI:1992770333
Name:ROPPOLO, JOHN KYLE (PA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:KYLE
Last Name:ROPPOLO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11271 FLORIDA BLVD.
Mailing Address - Street 2:APT. 213
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70815-2061
Mailing Address - Country:US
Mailing Address - Phone:225-278-6766
Mailing Address - Fax:
Practice Address - Street 1:7777 HENNESSY BLVD.
Practice Address - Street 2:SUITE 208
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4300
Practice Address - Country:US
Practice Address - Phone:225-765-7163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200049363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1581721Medicaid
LA1581721Medicaid
LA5CE47P729Medicare ID - Type Unspecified
LA5CQ60P618Medicare PIN