Provider Demographics
NPI:1770057812
Name:ROTH, HANNAH L (PA-C)
Entity type:Individual
Prefix:
First Name:HANNAH
Middle Name:L
Last Name:ROTH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HANNAH
Other - Middle Name:L
Other - Last Name:WEAVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2626 N WEBB RD
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-8110
Mailing Address - Country:US
Mailing Address - Phone:166-366-1273
Mailing Address - Fax:316-636-5813
Practice Address - Street 1:2626 N WEBB RD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-8110
Practice Address - Country:US
Practice Address - Phone:316-636-6127
Practice Address - Fax:316-636-5813
Is Sole Proprietor?:No
Enumeration Date:2019-01-11
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
KS15-02185363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical