Provider Demographics
NPI:1013929736
Name:ROTH, LORI R (PA-C)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:R
Last Name:ROTH
Suffix:
Gender:F
Credentials:PA-C
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 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:214-645-8000
Mailing Address - Fax:214-645-0078
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7201
Practice Address - Country:US
Practice Address - Phone:214-645-8000
Practice Address - Fax:214-645-0078
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05949363A00000X
NJ25MP00162500363A00000X
PAMA056254363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L2705Medicare PIN
TX8Y9084OtherBCBS
TXTXB109591 - HOODMedicare PIN
NJQ72125Medicare UPIN
TXP00658225OtherRAILROAD MEDICARE
TX197416401Medicaid