Active NPI
Jennifer D Roth, PA
- Physician Assistant
- Glen Cove, NY
National Provider Identifier
1063636280
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physician Assistant
- License
- 009096
- Practice address
- 104 Forest Ave
Glen Cove, NY 11542-2015 - Phone
- (516) 759-5406
- NPI assigned
- Apr 11, 2007
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | 009096 | NY | Primary |
Addresses
Primary practice location
104 Forest Ave
Glen Cove, NY 11542-2015
Mailing address
4626 217TH St
Bayside, NY 11361-3530
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: No
- Medical equipment: Yes
- Home health: No
- Power mobility devices: Yes
- Hospice: No
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 009096 | NY | MD | Registered Dietitian |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1176249600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1063636280",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4626 217TH ST",
"city": "BAYSIDE",
"state": "NY",
"postal_code": "113613530"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "104 FOREST AVE",
"city": "GLEN COVE",
"state": "NY",
"postal_code": "115422015",
"telephone_number": "516-759-5406"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ROTH",
"first_name": "JENNIFER",
"middle_name": "D",
"credential": "PA",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2007-04-11",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "NY",
"license": "009096",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Glen Cove, NY
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.