MEDICARE: KATHLEEN MARIE ROTH PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	MA055869	PA

General Provider Information

NPI Number	:	1538405279
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN MARIE ROTH PA-C

Provider Business Mailing Address
First Line	:	389 BANBURY DR
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14612-5918
Country	:	US
Telephone Number	:	585-705-7214
Fax Number	:

Provider Business Practice Location Address
First Line	:	5201 BAUM BLVD
Second Line	:	SHADYSIDE MEDEXPRESS
City	:	PITTSBURGH
State	:	PA
Zip	:	15224-2303
Country	:	US
Telephone Number	:	412-687-3627
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2012
Last Update Date	:	12/28/2012

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