Provider Demographics
NPI:1386067593
Name:ROTH, AMBER LEIGH (APRN)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:LEIGH
Last Name:ROTH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5012 US HWY 75 S, SUITE 300
Mailing Address - Street 2:ATT: IPM CREDENTIALING
Mailing Address - City:DENISON
Mailing Address - State:TX
Mailing Address - Zip Code:75020
Mailing Address - Country:US
Mailing Address - Phone:806-351-7600
Mailing Address - Fax:
Practice Address - Street 1:1411 EAST AMARILLO BLVD
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79107-1770
Practice Address - Country:US
Practice Address - Phone:806-351-7510
Practice Address - Fax:806-351-7274
Is Sole Proprietor?:No
Enumeration Date:2014-01-23
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX756264363LF0000X
TXAP124867363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX352273ZHHLMedicare PIN