Provider Demographics
NPI:1831447770
Name:ROTH, NICOLE (PA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:ANINOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1500 SANDPOINT RD
Mailing Address - Street 2:
Mailing Address - City:MUNISING
Mailing Address - State:MI
Mailing Address - Zip Code:49862-1406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 SANDPOINT RD
Practice Address - Street 2:
Practice Address - City:MUNISING
Practice Address - State:MI
Practice Address - Zip Code:49862-1406
Practice Address - Country:US
Practice Address - Phone:906-387-4110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006425363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI23-8650OtherRHC CERTIFICATION NUMBER