Provider Demographics
NPI:1386372050
Name:ROTH, NICHOLAS JAMES (PA-C)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JAMES
Last Name:ROTH
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 1:136 KINSELLA AVE
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-3337
Mailing Address - Country:US
Mailing Address - Phone:516-462-2001
Mailing Address - Fax:
Practice Address - Street 1:136 KINSELLA AVE
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA PARK
Practice Address - State:NY
Practice Address - Zip Code:11762-3337
Practice Address - Country:US
Practice Address - Phone:516-462-2001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant