Provider Demographics
NPI:1568715282
Name:ROTH, ALICIA (PA)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:PA
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Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1601 MONTE VISTA AVE
Mailing Address - Street 2:SUITE 190
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-2962
Mailing Address - Country:US
Mailing Address - Phone:909-865-9501
Mailing Address - Fax:909-946-0211
Practice Address - Street 1:1601 MONTE VISTA AVE
Practice Address - Street 2:SUITE 190
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-2962
Practice Address - Country:US
Practice Address - Phone:909-865-9501
Practice Address - Fax:909-946-0211
Is Sole Proprietor?:No
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAPA 21924363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant