Provider Demographics
NPI:1164504403
Name:ROTH, DANNY JOE (CRNA, APN)
Entity Type:Individual
Prefix:MR
First Name:DANNY
Middle Name:JOE
Last Name:ROTH
Suffix:
Gender:M
Credentials:CRNA, APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2460 TOPEKA DRIVE
Mailing Address - Street 2:
Mailing Address - City:NORTH POLE
Mailing Address - State:AK
Mailing Address - Zip Code:99705-2460
Mailing Address - Country:US
Mailing Address - Phone:423-315-6338
Mailing Address - Fax:
Practice Address - Street 1:1650 COWLES ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5998
Practice Address - Country:US
Practice Address - Phone:907-388-6852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12213367500000X
AK384367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered