Provider Demographics
NPI:1164400057
Name:ROETHLER, TRAVIS L (PA-C)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:L
Last Name:ROETHLER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:924 1ST ST NE
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-5441
Mailing Address - Country:US
Mailing Address - Phone:507-333-3300
Mailing Address - Fax:507-333-3214
Practice Address - Street 1:300 STATE AVE
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-6319
Practice Address - Country:US
Practice Address - Phone:507-333-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9141363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN312373100Medicaid
MN970015376Medicare ID - Type UnspecifiedRAILROAD
MN312373100Medicaid
R90125Medicare UPIN