Provider Demographics
NPI:1316614944
Name:ROTH, LAURA BLAKE (PA-C)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:BLAKE
Last Name:ROTH
Suffix:
Gender:F
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 1:301 LIPPINCOTT DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4197
Mailing Address - Country:US
Mailing Address - Phone:856-247-7210
Mailing Address - Fax:856-247-7511
Practice Address - Street 1:212 CREEK CROSSING BLVD.
Practice Address - Street 2:
Practice Address - City:HAINESPORT
Practice Address - State:NJ
Practice Address - Zip Code:08036
Practice Address - Country:US
Practice Address - Phone:856-206-4795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-23
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
NJ25MP00817500363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical