Provider Demographics
NPI:1053866764
Name:ROTBERG, MARY ELIZABETH (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:ROTBERG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:19075 NW TANASBOURNE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-5866
Mailing Address - Country:US
Mailing Address - Phone:503-941-3844
Mailing Address - Fax:
Practice Address - Street 1:202 NW 13TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2953
Practice Address - Country:US
Practice Address - Phone:503-941-3844
Practice Address - Fax:503-941-3777
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-23
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201606595NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR201606595NP-PPOtherNP LICENSE