Provider Demographics
NPI:1750040549
Name:RODRIGUEZ ROTH, CARLOS MANUEL (PA)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:MANUEL
Last Name:RODRIGUEZ ROTH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB. VALLE ALTO CALLE LOMA #2386
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00730-4145
Mailing Address - Country:US
Mailing Address - Phone:787-599-8148
Mailing Address - Fax:
Practice Address - Street 1:URB. VALLE ALTO CALLE LOMA #2386
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00730-4145
Practice Address - Country:US
Practice Address - Phone:787-599-8148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1121363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical