Provider Demographics
NPI:1215445234
Name:ROUTH, CHRISTINE ALESI (PA-C)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:ALESI
Last Name:ROUTH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:A
Other - Last Name:LENIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 10880
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-0880
Mailing Address - Country:US
Mailing Address - Phone:928-759-5874
Mailing Address - Fax:928-458-2039
Practice Address - Street 1:7700 E FLORENTINE RD STE 101
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-2245
Practice Address - Country:US
Practice Address - Phone:928-442-8710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6969363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1146610OtherNCCPA BOARD CERTIFICATION
AZ459138Medicaid
AZ6969OtherAZ REGULATORY BOARD OF PHYSICIAN ASSISTANTS