Provider Demographics
NPI:1780829796
Name:ROTH, STEVEN J (PA)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:J
Last Name: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 1:4 ERIC RD
Mailing Address - Street 2:
Mailing Address - City:MULLICA HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08062-9547
Mailing Address - Country:US
Mailing Address - Phone:856-223-9646
Mailing Address - Fax:856-223-9646
Practice Address - Street 1:4 ERIC RD
Practice Address - Street 2:
Practice Address - City:MULLICA HILL
Practice Address - State:NJ
Practice Address - Zip Code:08062-9547
Practice Address - Country:US
Practice Address - Phone:856-223-9646
Practice Address - Fax:856-223-9646
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-04
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000905363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant