Provider Demographics
NPI:1689029852
Name:ROTH, NICOLE Y (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:Y
Last Name:ROTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:NICOLE
Other - Middle Name:Y
Other - Last Name:COPPAGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:560 CATALINA DR STE 200
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-1605
Mailing Address - Country:US
Mailing Address - Phone:541-201-4850
Mailing Address - Fax:
Practice Address - Street 1:560 CATALINA DR STE 200
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-1605
Practice Address - Country:US
Practice Address - Phone:541-201-4850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-25
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60964584207V00000X, 207Q00000X
WAML60677475390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORMD201104OtherOREGON DEPARTMENT OF HEALTH