Provider Demographics
NPI:1225063936
Name:ROTH, LINCOLN R (CRNA)
Entity Type:Individual
Prefix:
First Name:LINCOLN
Middle Name:R
Last Name:ROTH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 BUNKER HILL DR
Mailing Address - Street 2:
Mailing Address - City:AITKIN
Mailing Address - State:MN
Mailing Address - Zip Code:56431-1865
Mailing Address - Country:US
Mailing Address - Phone:218-927-5522
Mailing Address - Fax:
Practice Address - Street 1:200 BUNKER HILL DR
Practice Address - Street 2:
Practice Address - City:AITKIN
Practice Address - State:MN
Practice Address - Zip Code:56431-1865
Practice Address - Country:US
Practice Address - Phone:218-927-5522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR030067367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE460224743-48Medicaid
SD5754210Medicaid
IA0585463Medicaid
SD5754214Medicaid
MN415T5ROOtherMN BLUE CROSS BS
SD4995584OtherBLUE CROSS OF SD
MN871418500Medicaid
MN415T5ROOtherMN BLUE CROSS BS
NE460224743-48Medicaid
SD5754214Medicaid
SDS41730Medicare PIN