Provider Demographics
NPI:1316906076
Name:ROTH, SUZANNE FAIR (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MISS
First Name:SUZANNE
Middle Name:FAIR
Last Name:ROTH
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
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 81524
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92138-1524
Mailing Address - Country:US
Mailing Address - Phone:619-889-7684
Mailing Address - Fax:619-889-7684
Practice Address - Street 1:1501 FRONT ST
Practice Address - Street 2:643
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2973
Practice Address - Country:US
Practice Address - Phone:619-889-7684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14948363AM0700X
CARN 252378363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical