Healthcare Provider Details

I. General information

NPI: 1194876649
Provider Name (Legal Business Name): JOANNA GAYLE ROLEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 11/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7777 FOREST LN SUITE B332
DALLAS TX
75230-2571
US

IV. Provider business mailing address

PO BOX 1810
SKYLAND NC
28776-1810
US

V. Phone/Fax

Practice location:
  • Phone: 972-566-7788
  • Fax: 972-566-8837
Mailing address:
  • Phone: 828-575-2644
  • Fax: 828-350-2174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01711
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: