Provider Demographics
NPI:1285056291
Name:ROTT, ALLISON RENEE (PAC)
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:RENEE
Last Name:ROTT
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3808
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3808
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:205 SE SPOKANE ST STE 300
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-6487
Practice Address - Country:US
Practice Address - Phone:303-929-8993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-09
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA166253363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500667230Medicaid
WA1285056291Medicaid
OR500667230Medicaid
WA1285056291Medicaid