Provider Demographics
NPI:1730273632
Name:ROETTER, BEVERLY YESHION (ARNP)
Entity type:Individual
Prefix:MRS
First Name:BEVERLY
Middle Name:YESHION
Last Name:ROETTER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 E BRANDON BLVD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5219
Mailing Address - Country:US
Mailing Address - Phone:813-829-0133
Mailing Address - Fax:813-681-4391
Practice Address - Street 1:128 E BRANDON BLVD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5219
Practice Address - Country:US
Practice Address - Phone:813-829-0133
Practice Address - Fax:813-681-4391
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 1075742363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS76639Medicare UPIN
FLY6764WMedicare ID - Type UnspecifiedMEDICARE ID #
FLS76639Medicare UPIN