Provider Demographics
NPI:1255860029
Name:ROTH, MICHAEL ANDREW (CAA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ANDREW
Last Name:ROTH
Suffix:
Gender:M
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3645 NW BLUE JACKET DR
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64064-3017
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 NW R D MIZE RD
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014-2513
Practice Address - Country:US
Practice Address - Phone:816-228-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-06
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017017852367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO58303041OtherBCBS KC
MOP02320854OtherRAILROAD
MO1255860029Medicaid