Provider Demographics
NPI:1083795835
Name:ROTH, KATELYN MCNULTY (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:KATELYN
Middle Name:MCNULTY
Last Name:ROTH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:MARIE
Other - Last Name:MCNULTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:75 FRANCIS STREET
Mailing Address - Street 2:BRIGHAM AND WOMEN'S HOSPITAL
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115
Mailing Address - Country:US
Mailing Address - Phone:617-732-5349
Mailing Address - Fax:617-738-7064
Practice Address - Street 1:75 FRANCIS STREET
Practice Address - Street 2:BRIGHAM AND WOMEN'S HOSPITAL
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115
Practice Address - Country:US
Practice Address - Phone:617-732-5349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2167363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant