Healthcare Provider Details

I. General information

NPI: 1235436791
Provider Name (Legal Business Name): MICHAEL SP ROACH FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2011
Last Update Date: 02/25/2025
Certification Date: 02/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1514 LYNNVIEW DR
HOUSTON TX
77055-3428
US

IV. Provider business mailing address

325 W 20TH ST
HOUSTON TX
77008-2436
US

V. Phone/Fax

Practice location:
  • Phone: 832-857-0062
  • Fax: 346-299-7263
Mailing address:
  • Phone: 713-868-4433
  • Fax: 713-868-4747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number751075
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: