Provider records sourced from NPPES (CMS National Plan & Provider Enumeration System). Data current as of August 10, 2026.
NPIDirectory

Mrs. Michelle L Roth, PA

Individual provider Physician Assistant · NPI 1477743813

Mrs. Michelle L Roth, PA is a Physician Assistant in Peoria, Illinois. Qualified in 2007, 19 years ago. Practices with Soderstrom Dermatology Center S C, a 33-clinician group and accepts Medicare assignment. Licensed in Illinois.

Years since qualifying
19
Licensed in
IL
In the registry since
2007
What do these letters mean?
PA — Physician Assistant
A licensed clinician who examines, diagnoses and treats under a physician's supervision.

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Practice location Address checks out

4909 N Glen Park Place Rd
Peoria, IL 61614-4676
Phone: (309) 674-7546
Fax: (309) 282-0500
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Pin is approximate — placed at the ZIP-code centre, not the exact door.

Specialties & licences

Physician Assistant (primary) Taxonomy 363A00000X (IL)

Record details

NPI number1477743813
Entity typeIndividual (Type 1)
GenderFemale
Credentials PA
Sole proprietorNo
NPI enumeratedAugust 1, 2007
Last updated in NPPESAugust 1, 2007

Medicare enrollment

From the CMS Doctors & Clinicians file — this clinician is enrolled in Medicare.

Medicare specialtyPHYSICIAN ASSISTANT
Medical schoolOTHER
Graduated 2007 (19 years in practice)
Group practice Soderstrom Dermatology Center S C — 33 clinicians
Accepts Medicare assignment Yes — accepts the Medicare-approved amount
Practice locations4 on file with Medicare

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