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General NPI Number Information
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NPI Number | 1770772865
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Entity Type | Individual
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Provider Name | LEIGH DIANE ROTH PA-C
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Gender | Female
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Dates
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Enumeration Date | 10/15/2007
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Last Update Date | 12/21/2015
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Provider Practice Location Address
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Address Line | 2165 MEDICAL PARK DR
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City | HICKORY
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State | NC
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Zip | 28602-8809
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Country | US
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Telephone | 828-324-2800
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Fax | 828-294-9141
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Provider Business Mailing Address
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Address Line | 2165 MEDICAL PARK DR
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City | HICKORY
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State | NC
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Zip | 28602-8809
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Country | US
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Telephone | 828-324-2800
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Fax | 828-294-9141
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 0010-06090
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 085.003735
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 10374
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License Number State | MN
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