Healthcare Provider Details

I. General information

NPI: 1710486485
Provider Name (Legal Business Name): OHIO PA SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2018
Last Update Date: 01/23/2023
Certification Date: 01/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 HIDDEN RAVINES DR
POWELL OH
43065
US

IV. Provider business mailing address

1141 N LOOP 1604 E #105-612
SAN ANTONIO TX
78232
US

V. Phone/Fax

Practice location:
  • Phone: 210-598-4262
  • Fax:
Mailing address:
  • Phone: 210-598-4262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: ROXANNA LAROQUE
Title or Position: DIRECTOR OF CLIENT EXPERIENCE
Credential:
Phone: 210-598-4277