Provider Demographics
NPI:1245209261
Name:ROTHER, JEANNINE MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JEANNINE
Middle Name:MARIE
Last Name:ROTHER
Suffix:
Gender:F
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 1:121 EVERETT ROAD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205
Mailing Address - Country:US
Mailing Address - Phone:518-453-9088
Mailing Address - Fax:518-689-3895
Practice Address - Street 1:121 EVERETT ROAD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205
Practice Address - Country:US
Practice Address - Phone:518-453-9088
Practice Address - Fax:518-689-3895
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009978-1363AS0400X
NY363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03094153Medicaid