Provider Demographics
NPI:1982362950
Name:ROTH, DANIEL WILLIAM (FNP-BC)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:WILLIAM
Last Name:ROTH
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8766 EVAN LILAS ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-5112
Mailing Address - Country:US
Mailing Address - Phone:702-335-7290
Mailing Address - Fax:
Practice Address - Street 1:8766 EVAN LILAS ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-5112
Practice Address - Country:US
Practice Address - Phone:702-335-7290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV848817363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily