Provider Demographics
NPI:1093714784
Name:ROTH, KAREN S (ANP-BC, ACHPN)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:S
Last Name:ROTH
Suffix:
Gender:F
Credentials:ANP-BC, ACHPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4195 W WALWORTH RD
Mailing Address - Street 2:
Mailing Address - City:MACEDON
Mailing Address - State:NY
Mailing Address - Zip Code:14502-9313
Mailing Address - Country:US
Mailing Address - Phone:315-986-5771
Mailing Address - Fax:
Practice Address - Street 1:1208 DRIVING PARK AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-1057
Practice Address - Country:US
Practice Address - Phone:315-359-2640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF300625363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400000753Medicare PIN
NYPOO674192Medicare PIN