Individual
LUCAS B ROTH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
6000 N ALLEN RD, PEORIA, IL 61614-3294
(309) 691-1400
(309) 693-3197
Mailing address
6000 N ALLEN RD, PEORIA, IL 61614-3294
(309) 691-1400
(309) 693-3197
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
085006385
IL
363AS0400X
Surgical Physician Assistant
Primary
085006385
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
085006385
—
IL
Enumeration date
10/06/2017
Last updated
06/19/2025
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