Provider Demographics
NPI:1871614438
Name:ROTH, MARTHA (CNM)
Entity type:Individual
Prefix:MS
First Name:MARTHA
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 FIRST AVE
Mailing Address - Street 2:
Mailing Address - City:NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10960-2114
Mailing Address - Country:US
Mailing Address - Phone:845-535-5133
Mailing Address - Fax:845-231-6220
Practice Address - Street 1:20 FIRST AVE
Practice Address - Street 2:
Practice Address - City:NYACK
Practice Address - State:NY
Practice Address - Zip Code:10960-2114
Practice Address - Country:US
Practice Address - Phone:845-535-5133
Practice Address - Fax:845-231-6220
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000583F367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01727600Medicaid