Healthcare Provider Details

I. General information

NPI: 1083124846
Provider Name (Legal Business Name): LUCAS B ROTH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2017
Last Update Date: 06/19/2025
Certification Date: 06/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 N ALLEN RD
PEORIA IL
61614-3294
US

IV. Provider business mailing address

6000 N ALLEN RD
PEORIA IL
61614-3294
US

V. Phone/Fax

Practice location:
  • Phone: 309-691-1400
  • Fax: 309-693-3197
Mailing address:
  • Phone: 309-691-1400
  • Fax: 309-693-3197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085006385
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number085006385
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: