MEDICARE: SUSAN M ROCHE CRNP

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	163WX0200X	Oncology Registered Nurse	RN224580L	PA
2	363L00000X	Nurse Practitioner	VP003651C	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	002105227	OTHER	PA	HIGHMARK

General Provider Information

NPI Number	:	1629117197
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN M ROCHE CRNP

Provider Business Mailing Address
First Line	:	2500 W 12TH ST
Second Line	:
City	:	ERIE
State	:	PA
Zip	:	16505-4508
Country	:	US
Telephone Number	:	814-838-9000
Fax Number	:

Provider Business Practice Location Address
First Line	:	2500 W 12TH ST
Second Line	:
City	:	ERIE
State	:	PA
Zip	:	16505-4508
Country	:	US
Telephone Number	:	814-838-9000
Fax Number	:

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

Provider Enumeration Date	:	02/05/2007
Last Update Date	:	03/03/2010

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