Healthcare Provider Details

I. General information

NPI: 1770057812
Provider Name (Legal Business Name): HANNAH L ROTH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HANNAH L WEAVER PA-C

II. Dates (important events)

Enumeration Date: 01/11/2019
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2626 N WEBB RD
WICHITA KS
67226-8110
US

IV. Provider business mailing address

2626 N WEBB RD
WICHITA KS
67226-8110
US

V. Phone/Fax

Practice location:
  • Phone: 316-636-6127
  • Fax: 316-636-5813
Mailing address:
  • Phone: 166-366-1273
  • Fax: 316-636-5813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15-02185
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: