Healthcare Provider Details

I. General information

NPI: 1174404578
Provider Name (Legal Business Name): AVERY RHEANN ROLSTEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7950 W JEFFERSON BLVD
FORT WAYNE IN
46804-4140
US

IV. Provider business mailing address

10184 DULL ROBINSON RD
VAN WERT OH
45891-8948
US

V. Phone/Fax

Practice location:
  • Phone: 260-435-7001
  • Fax:
Mailing address:
  • Phone: 800-342-2898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10005071A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberPENDING
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: