Provider Demographics
NPI:1306249180
Name:ROEUM, KEVIN ROTH (PA-C)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:ROTH
Last Name:ROEUM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13254 COPLAND CT
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-7105
Mailing Address - Country:US
Mailing Address - Phone:301-910-2107
Mailing Address - Fax:
Practice Address - Street 1:13254 COPLAND CT
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-7105
Practice Address - Country:US
Practice Address - Phone:301-910-2107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-07
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC05534363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical