Healthcare Provider Details

I. General information

NPI: 1619967478
Provider Name (Legal Business Name): ARTHUR THOMAS ROACH P.A.-C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 11/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3040 GOODMAN ROAD, SUITE C
HORN LAKE MS
38637-1189
US

IV. Provider business mailing address

5185 NAIL ROAD
OLIVE BRANCH MS
38654-8245
US

V. Phone/Fax

Practice location:
  • Phone: 662-280-3428
  • Fax: 662-280-1736
Mailing address:
  • Phone: 662-895-6738
  • Fax: 662-280-1736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-025
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: