Provider Demographics
NPI:1619648805
Name:ROTH, ADAM CORGAN (PA-C)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:CORGAN
Last Name:ROTH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2147 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-0003
Mailing Address - Country:US
Mailing Address - Phone:989-732-1753
Mailing Address - Fax:
Practice Address - Street 1:2147 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-0003
Practice Address - Country:US
Practice Address - Phone:989-732-1753
Practice Address - Fax:989-731-1425
Is Sole Proprietor?:No
Enumeration Date:2021-09-27
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601010658363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant