MEDICARE: ROXANNE MONGEON PA

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	363AS0400X	Surgical Physician Assistant	000037	CT
2	363A00000X	Physician Assistant	PA10537	TX

General Provider Information

NPI Number	:	1538160593
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROXANNE MONGEON PA

Provider Business Mailing Address
First Line	:	2801 REGAL RD
Second Line	:	SUITE 108
City	:	PLANO
State	:	TX
Zip	:	75075-6315
Country	:	US
Telephone Number	:	972-599-0080
Fax Number	:	972-599-0082

Provider Business Practice Location Address
First Line	:	2801 REGAL RD
Second Line	:	SUITE 108
City	:	PLANO
State	:	TX
Zip	:	75075-6315
Country	:	US
Telephone Number	:	972-599-0080
Fax Number	:	972-599-0082

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

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	11/02/2016

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Directions to “ ROXANNE MONGEON PA” Practice Location

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