Healthcare Provider Details

I. General information

NPI: 1073227708
Provider Name (Legal Business Name): GABRIELLE NICOLE ROUX
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2023
Last Update Date: 04/19/2024
Certification Date: 04/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E WASHINGTON ST
MEDINA OH
44256-2170
US

IV. Provider business mailing address

5001 GREEN ASH TRL
MEDINA OH
44256-5575
US

V. Phone/Fax

Practice location:
  • Phone: 330-725-1000
  • Fax:
Mailing address:
  • Phone: 248-895-2504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: