Healthcare Provider Details

I. General information

NPI: 1083455182
Provider Name (Legal Business Name): KAITLYN ROEDER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2024
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 W ROBERTSON ST
BRANDON FL
33511-5007
US

IV. Provider business mailing address

PO BOX 25201
TAMPA FL
33622-5201
US

V. Phone/Fax

Practice location:
  • Phone: 813-701-5804
  • Fax: 813-291-7615
Mailing address:
  • Phone: 727-823-2188
  • Fax: 727-828-0723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9121071
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: