MEDICARE: ALICIA ROTH PA

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	PA 21924	CA

General Provider Information

NPI Number	:	1568715282
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALICIA ROTH PA

Provider Business Mailing Address
First Line	:	1601 MONTE VISTA AVE
Second Line	:	SUITE 190
City	:	CLAREMONT
State	:	CA
Zip	:	91711-2962
Country	:	US
Telephone Number	:	909-865-9501
Fax Number	:	909-946-0211

Provider Business Practice Location Address
First Line	:	1601 MONTE VISTA AVE
Second Line	:	SUITE 190
City	:	CLAREMONT
State	:	CA
Zip	:	91711-2962
Country	:	US
Telephone Number	:	909-865-9501
Fax Number	:	909-946-0211

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

Provider Enumeration Date	:	10/18/2012
Last Update Date	:	10/18/2012

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Directions to “ ALICIA ROTH PA” Practice Location

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