Healthcare Provider Details

I. General information

NPI: 1992424923
Provider Name (Legal Business Name): JEFFREY SCOTT ROTH FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2022
Last Update Date: 08/21/2023
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 N BEAVER ST
FLAGSTAFF AZ
86001-3120
US

IV. Provider business mailing address

1200 N BEAVER ST
FLAGSTAFF AZ
86001-3118
US

V. Phone/Fax

Practice location:
  • Phone: 928-773-2200
  • Fax: 928-773-2300
Mailing address:
  • Phone: 928-213-6235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number279848
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number279848
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: