Provider Demographics
NPI:1164689519
Name:ROTH, DARREN J (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DARREN
Middle Name:J
Last Name:ROTH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 801106
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-1106
Mailing Address - Country:US
Mailing Address - Phone:800-953-0104
Mailing Address - Fax:303-765-6670
Practice Address - Street 1:8990 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80229-4537
Practice Address - Country:US
Practice Address - Phone:303-665-3036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0002769363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO12025534Medicaid