Provider Demographics
NPI:1033462312
Name:ROTH, SANDRA M (ANP-C)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:M
Last Name:ROTH
Suffix:
Gender:F
Credentials:ANP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 RADBURN DR
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-1129
Mailing Address - Country:US
Mailing Address - Phone:631-864-5175
Mailing Address - Fax:
Practice Address - Street 1:52 RADBURN DR
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-1129
Practice Address - Country:US
Practice Address - Phone:631-864-5175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-23
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF306134-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health