Provider Demographics
NPI:1316018518
Name:ROTH, TANJA N
Entity Type:Individual
Prefix:
First Name:TANJA
Middle Name:N
Last Name:ROTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 SW 7TH ST
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66606-2330
Mailing Address - Country:US
Mailing Address - Phone:785-273-2252
Mailing Address - Fax:785-273-7489
Practice Address - Street 1:330 SW OAKLEY AVE
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66606-1995
Practice Address - Country:US
Practice Address - Phone:785-233-1730
Practice Address - Fax:785-354-1068
Is Sole Proprietor?:No
Enumeration Date:2006-11-11
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS74856363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q36319Medicare UPIN
161435Medicare UPIN