Basic Information
| Provider Information | |||||||||
| NPI: | 1558315325 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FLETCHER | ||||||||
| FirstName: | ROCKY | ||||||||
| MiddleName: | J | ||||||||
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| Mailing Information | |||||||||
| Address1: | 233 W FIRST ST | ||||||||
| Address2: | |||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55387 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524429770 | ||||||||
| FaxNumber: | 9524423620 | ||||||||
| Practice Location | |||||||||
| Address1: | 1825 LOGAN AVE | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507031999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192353886 | ||||||||
| FaxNumber: | 3192331630 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 01/28/2008 | ||||||||
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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 | D-058051 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 43339 | 01 | IA | WELLMARK INS PLAN | OTHER | 10745 | 01 | IA | MIDLANDS CHOICE | OTHER | 2267047 | 05 | IA | MEDICAID | 26585 | 01 | IA | BLUE CROSS OF IA | OTHER | 421417307A6 | 01 | IA | JOHN DEERE HEALTH INS | OTHER |