Healthcare Provider Details

I. General information

NPI: 1538523584
Provider Name (Legal Business Name): JACOB ROUQUETTE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2016
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5830 NW BARRY RD
KANSAS CITY MO
64154-2778
US

IV. Provider business mailing address

5830 NW BARRY RD
KANSAS CITY MO
64154-2778
US

V. Phone/Fax

Practice location:
  • Phone: 816-932-3679
  • Fax: 816-932-9089
Mailing address:
  • Phone: 816-932-3679
  • Fax: 816-932-9089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2016018500
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: