Basic Information
| Provider Information | |||||||||
| NPI: | 1023425600 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROACHE | ||||||||
| FirstName: | GAVIN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 S FRONT ST | ||||||||
| Address2: | |||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171012010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8633709555 | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 S FRONT ST | ||||||||
| Address2: | |||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171012010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177823131 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2014 | ||||||||
| LastUpdateDate: | 04/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | SP021669 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LF0000X | APRN11004127 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | SP021669 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 016388100 | 05 | FL | MEDICAID |