Provider Demographics
NPI:1033533476
Name:ROTH, EMILY T (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:T
Last Name:ROTH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:P
Other - Last Name:TOWNSEND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:825 N GRAND AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:NOGALES
Mailing Address - State:AZ
Mailing Address - Zip Code:85621-1061
Mailing Address - Country:US
Mailing Address - Phone:520-761-2133
Mailing Address - Fax:520-281-1112
Practice Address - Street 1:1209 W TARGET RANGE RD
Practice Address - Street 2:
Practice Address - City:NOGALES
Practice Address - State:AZ
Practice Address - Zip Code:85621-2466
Practice Address - Country:US
Practice Address - Phone:520-761-2133
Practice Address - Fax:520-281-1112
Is Sole Proprietor?:No
Enumeration Date:2014-02-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP9710363LW0102X
TN190075363LW0102X
KY1138002363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ223392Medicaid