=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265810865
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MEGHAN ROARK PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2015
-----------------------------------------------------
Last Update Date | 12/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2920 N EASTMAN RD
-----------------------------------------------------
City | LONGVIEW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75605-5099
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-757-6020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1209 NW 36TH ST
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73118-5603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-826-2264
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 2135680
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------