Provider Demographics
NPI:1902814718
Name:ROTH, LOUIS (CRNA)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:
Last Name:ROTH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 BUSINESS PARK DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-6523
Mailing Address - Country:US
Mailing Address - Phone:757-473-0055
Mailing Address - Fax:
Practice Address - Street 1:1060 FIRST COLONIAL RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-3002
Practice Address - Country:US
Practice Address - Phone:757-395-8369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA24166055367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00098117Medicare PIN
004391A26Medicare ID - Type Unspecified