Provider Demographics
NPI:1992466833
Name:ROTH, CLAY (PTA)
Entity type:Individual
Prefix:MR
First Name:CLAY
Middle Name:
Last Name:ROTH
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:592 LINCOLN AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-3197
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4080 W BROADWAY AVE STE 200
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-5606
Practice Address - Country:US
Practice Address - Phone:763-398-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-03
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant