Provider Demographics
NPI:1770767360
Name:ROTH, JOHN R (MPAS, PA-C)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:R
Last Name:ROTH
Suffix:
Gender:M
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 741825
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-1825
Mailing Address - Country:US
Mailing Address - Phone:503-362-8385
Mailing Address - Fax:503-362-8435
Practice Address - Street 1:920 COUNTRY CLUB RD STE 140A
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-6024
Practice Address - Country:US
Practice Address - Phone:503-362-8385
Practice Address - Fax:503-362-8435
Is Sole Proprietor?:No
Enumeration Date:2007-12-19
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORPA01418363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program