Provider Demographics
NPI:1467618785
Name:ROTH, MARY A (FNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:ROTH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 SOUTH 65 HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MO
Mailing Address - Zip Code:65340-3702
Mailing Address - Country:US
Mailing Address - Phone:660-886-7800
Mailing Address - Fax:660-831-3328
Practice Address - Street 1:2301 SOUTH 65 HIGHWAY
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MO
Practice Address - Zip Code:65340-3702
Practice Address - Country:US
Practice Address - Phone:660-886-7800
Practice Address - Fax:660-886-3328
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO149803363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily