MEDICARE: MRS. AVERY RHEANN ROLSTEN PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	10005071A	IN
2	207P00000X	Emergency Medicine Physician	PENDING	IN

General Provider Information

NPI Number	:	1174404578
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AVERY RHEANN ROLSTEN PA-C

Provider Business Mailing Address
First Line	:	10184 DULL ROBINSON RD
Second Line	:
City	:	VAN WERT
State	:	OH
Zip	:	45891-8948
Country	:	US
Telephone Number	:	800-342-2898
Fax Number	:

Provider Business Practice Location Address
First Line	:	7950 W JEFFERSON BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-4140
Country	:	US
Telephone Number	:	260-435-7001
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/11/2025
Last Update Date	:	12/15/2025

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