Provider Demographics
NPI:1538160593
Name:MONGEON, ROXANNE (PA)
Entity type:Individual
Prefix:
First Name:ROXANNE
Middle Name:
Last Name:MONGEON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 REGAL RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75075-6315
Mailing Address - Country:US
Mailing Address - Phone:972-599-0080
Mailing Address - Fax:972-599-0082
Practice Address - Street 1:2801 REGAL RD
Practice Address - Street 2:SUITE 108
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-6315
Practice Address - Country:US
Practice Address - Phone:972-599-0080
Practice Address - Fax:972-599-0082
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000037363AS0400X
TXPA10537363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT970000523Medicare ID - Type Unspecified
CTS29461Medicare UPIN