Healthcare Provider Details

I. General information

NPI: 1134649684
Provider Name (Legal Business Name): ANDREW PATRICK ROCHE III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2017
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1599 JONES ST
GRAND FORKS ND
58205-6306
US

IV. Provider business mailing address

1599 JONES STREET
GRAND FORKS AFB ND
58204
US

V. Phone/Fax

Practice location:
  • Phone: 701-747-5504
  • Fax:
Mailing address:
  • Phone: 701-747-5504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number31110
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: