Healthcare Provider Details

I. General information

NPI: 1467802892
Provider Name (Legal Business Name): MARK CHRISTOPHER ROQUE APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2016
Last Update Date: 06/05/2020
Certification Date: 06/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13933 17TH ST SUITE 101
DADE CITY FL
33525-4604
US

IV. Provider business mailing address

13933 17TH ST SUITE 101
DADE CITY FL
33525-4604
US

V. Phone/Fax

Practice location:
  • Phone: 352-567-6763
  • Fax: 352-567-2146
Mailing address:
  • Phone: 352-567-6763
  • Fax: 352-567-2146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN3091802
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: