Basic Information
| Provider Information | |||||||||
| NPI: | 1194876649 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROLEN | ||||||||
| FirstName: | JOANNA | ||||||||
| MiddleName: | GAYLE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1810 | ||||||||
| Address2: | |||||||||
| City: | SKYLAND | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287761810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285752644 | ||||||||
| FaxNumber: | 8283502174 | ||||||||
| Practice Location | |||||||||
| Address1: | 7777 FOREST LN | ||||||||
| Address2: | SUITE B332 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752302571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9725667788 | ||||||||
| FaxNumber: | 9725668837 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2007 | ||||||||
| LastUpdateDate: | 11/17/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA01711 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 408121ZM3L | 01 | TX | MEDICARE PTAN | OTHER | TXB115001 | 01 | TX | MEDICARE PTAN | OTHER | 408121ZM3J | 01 | TX | MEDICARE PTAN | OTHER | TXB115000 | 01 | TX | MEDICARE PTAN | OTHER |