Provider Demographics
NPI:1447355920
Name:ROTH, MICHAEL (CRNA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:ROTH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14525 326TH RD
Mailing Address - Street 2:
Mailing Address - City:WHITING
Mailing Address - State:KS
Mailing Address - Zip Code:66552-9510
Mailing Address - Country:US
Mailing Address - Phone:785-364-2116
Mailing Address - Fax:
Practice Address - Street 1:1110 COLUMBINE DR
Practice Address - Street 2:
Practice Address - City:HOLTON
Practice Address - State:KS
Practice Address - Zip Code:66436-8824
Practice Address - Country:US
Practice Address - Phone:785-364-2116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS37703367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered