MEDICARE: ALEJANDRA ANTONIETA ROA GONZALEZ

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	207RG0300X	Geriatric Medicine (Internal Medicine) Physician	154430	FL
2	207R00000X	Internal Medicine Physician	2023005483	MO

General Provider Information

NPI Number	:	1528527314
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEJANDRA ANTONIETA ROA GONZALEZ

Provider Business Mailing Address
First Line	:	2115 S FREMONT AVE STE 2300
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65804-2233
Country	:	US
Telephone Number	:	417-820-5600
Fax Number	:

Provider Business Practice Location Address
First Line	:	2115 S FREMONT AVE STE 2300
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65804-2233
Country	:	US
Telephone Number	:	417-820-5600
Fax Number	:

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

Provider Enumeration Date	:	03/19/2019
Last Update Date	:	08/07/2024

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