Basic Information
| Provider Information | |||||||||
| NPI: | 1306203641 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | ERIC | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1347 NEVINS STATION RD | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403429759 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1011 OLD HIGHWAY 60 | ||||||||
| Address2: | |||||||||
| City: | HARDINSBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707567000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2016 | ||||||||
| LastUpdateDate: | 11/25/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 700663 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 3010062 | 01 | KY | APRN LICENSE | OTHER | 700663 | 01 | KY | CRNA CERTIFICATION | OTHER |