Provider Demographics
NPI:1609462589
Name:RODERICK, AMRITA KAUR (PA-C)
Entity type:Individual
Prefix:
First Name:AMRITA
Middle Name:KAUR
Last Name:RODERICK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMRITA
Other - Middle Name:KAUR
Other - Last Name:JAGPAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 837
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45012-0837
Mailing Address - Country:US
Mailing Address - Phone:513-454-1111
Mailing Address - Fax:
Practice Address - Street 1:1036 S VERITY PKWY
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-5513
Practice Address - Country:US
Practice Address - Phone:513-454-1460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-15
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.006805RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0432310Medicaid