Provider Demographics
NPI:1669012282
Name:ROTH, RACHEL ERIN
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:ERIN
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 1:180 JOHN F KENNEDY DR STE 100
Mailing Address - Street 2:
Mailing Address - City:ATLANTIS
Mailing Address - State:FL
Mailing Address - Zip Code:33462-6641
Mailing Address - Country:US
Mailing Address - Phone:561-967-6500
Mailing Address - Fax:
Practice Address - Street 1:180 JOHN F KENNEDY DR STE 100
Practice Address - Street 2:
Practice Address - City:ATLANTIS
Practice Address - State:FL
Practice Address - Zip Code:33462-6641
Practice Address - Country:US
Practice Address - Phone:561-967-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-11
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9114988363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant