Provider Demographics
NPI:1770191405
Name:ROETHELE, CLAIRE (PA)
Entity Type:Individual
Prefix:
First Name:CLAIRE
Middle Name:
Last Name:ROETHELE
Suffix:
Gender:F
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:PO BOX 45171
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70895-4171
Mailing Address - Country:US
Mailing Address - Phone:225-928-2555
Mailing Address - Fax:225-929-9685
Practice Address - Street 1:500 RUE DE LA VIE ST STE 405
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70817-5128
Practice Address - Country:US
Practice Address - Phone:225-928-2555
Practice Address - Fax:225-929-9685
Is Sole Proprietor?:No
Enumeration Date:2020-07-20
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA323733363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA323733OtherLICENSE