MEDICARE: ADAM ROLLER APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	APRN-1711	HI
2	363LA2200X	Adult Health Nurse Practitioner	APRN-1711	HI

General Provider Information

NPI Number	:	1194143537
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ADAM ROLLER APRN

Provider Business Mailing Address
First Line	:	1245 KUALA ST
Second Line	:
City	:	PEARL CITY
State	:	HI
Zip	:	96782-3900
Country	:	US
Telephone Number	:	808-456-2273
Fax Number	:	808-456-2274

Provider Business Practice Location Address
First Line	:	91-1001 KAIMALIE ST STE 201B
Second Line	:
City	:	EWA BEACH
State	:	HI
Zip	:	96706-6250
Country	:	US
Telephone Number	:	808-762-0026
Fax Number	:	808-427-9397

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/02/2014
Last Update Date	:	02/13/2023

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