Healthcare Provider Details

I. General information

NPI: 1073332631
Provider Name (Legal Business Name): JACOB TODD ROTHFUSS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2024
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1319 SPERO RD
ASHEBORO NC
27205
US

IV. Provider business mailing address

300 E WENDOVER AVE
GREENSBORO NC
27401-1229
US

V. Phone/Fax

Practice location:
  • Phone: 336-890-4970
  • Fax: 336-890-4963
Mailing address:
  • Phone:
  • Fax: 336-890-4963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-14703
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0010-14703
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: