Provider Demographics
NPI:1093952657
Name:ROTHER, MARK BRYAN (BC-HIS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:BRYAN
Last Name:ROTHER
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12751 COUNTY ROAD 5
Mailing Address - Street 2:SUITE 198
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-2263
Mailing Address - Country:US
Mailing Address - Phone:952-808-9079
Mailing Address - Fax:952-882-9190
Practice Address - Street 1:12751 COUNTY ROAD 5
Practice Address - Street 2:SUITE 198
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-2263
Practice Address - Country:US
Practice Address - Phone:952-808-9079
Practice Address - Fax:952-882-9190
Is Sole Proprietor?:No
Enumeration Date:2009-01-19
Last Update Date:2009-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2287174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist