Healthcare Provider Details

I. General information

NPI: 1851920508
Provider Name (Legal Business Name): ROLKIN PETIT HOMME
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2020
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 DOGWOOD RD
WEST PALM BEACH FL
33409-6139
US

IV. Provider business mailing address

5069 OKEECHOBEE BLVD
WEST PALM BEACH FL
33417-4533
US

V. Phone/Fax

Practice location:
  • Phone: 773-977-6930
  • Fax:
Mailing address:
  • Phone: 561-667-4082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11034560
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberNJDATEMP-000486
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10171
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: