Basic Information
| Provider Information | |||||||||
| NPI: | 1558546788 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROATEN | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | BRENT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4100 LAKE OTIS PKWY STE 312 | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995085231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9079297337 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4100 LAKE OTIS PKWY STE 312 | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995085231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9079297337 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2008 | ||||||||
| LastUpdateDate: | 09/24/2019 | ||||||||
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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 | 2086S0120X | 43121 | TN | N | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery | 208600000X | 6550 | AK | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | MD1272 | 05 | AK | MEDICAID |