Provider Demographics
NPI:1114972858
Name:ROTH, CHRISTINE SUE (CRNA)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:SUE
Last Name:ROTH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:SUE
Other - Last Name:SIMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:901 MONTGOMERY ST
Mailing Address - Street 2:
Mailing Address - City:DECORAH
Mailing Address - State:IA
Mailing Address - Zip Code:52101-2325
Mailing Address - Country:US
Mailing Address - Phone:563-382-2911
Mailing Address - Fax:563-387-3102
Practice Address - Street 1:901 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:DECORAH
Practice Address - State:IA
Practice Address - Zip Code:52101-2325
Practice Address - Country:US
Practice Address - Phone:563-382-2911
Practice Address - Fax:563-387-3102
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAD102488367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1114972858Medicaid