Basic Information
| Provider Information | |||||||||
| NPI: | 1225453517 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROTH | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 ALBANY AVE | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061202508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602499625 | ||||||||
| FaxNumber: | 8608081580 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 KILLINGWORTH RD | ||||||||
| Address2: | |||||||||
| City: | HIGGANUM | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064414370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603458535 | ||||||||
| FaxNumber: | 8603458678 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2014 | ||||||||
| LastUpdateDate: | 10/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 994473 | CT | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 163W00000X | RN2284731 | MA | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 5832 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 5832 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.