Provider Demographics
NPI:1326019738
Name:ROSKOS, PENNY L (RN)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:L
Last Name:ROSKOS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:PENNY
Other - Middle Name:L
Other - Last Name:STAVLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:200 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55905-0001
Mailing Address - Country:US
Mailing Address - Phone:507-284-2511
Mailing Address - Fax:
Practice Address - Street 1:200 1ST ST SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55905-0001
Practice Address - Country:US
Practice Address - Phone:507-284-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR115129-1363L00000X
MN2010363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN383392500Medicaid
MN500001871Medicare ID - Type Unspecified
MN383392500Medicaid
P45991Medicare UPIN
MN500021908Medicare ID - Type UnspecifiedRAILROAD