Provider Demographics
NPI:1447682679
Name:ROGGOW, KATHRYN L (PAC)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:L
Last Name:ROGGOW
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:710 COMMERCE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-4925
Mailing Address - Country:US
Mailing Address - Phone:651-968-5201
Mailing Address - Fax:651-968-5904
Practice Address - Street 1:2620 EAGAN WOODS DR STE 100
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121-1138
Practice Address - Country:US
Practice Address - Phone:651-968-5201
Practice Address - Fax:651-968-5904
Is Sole Proprietor?:No
Enumeration Date:2013-07-30
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN11534363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400118302Medicare PIN
MN1447682679OtherBCBS OF MN
MN51447682679Medicaid
MN11534OtherLICENSE