Provider Demographics
NPI:1366485310
Name:POIRIER, ROBERTA RAE (CNM)
Entity Type:Individual
Prefix:MS
First Name:ROBERTA
Middle Name:RAE
Last Name:POIRIER
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 DUNCAN ROAD
Mailing Address - Street 2:
Mailing Address - City:BLOOMER
Mailing Address - State:WI
Mailing Address - Zip Code:54724
Mailing Address - Country:US
Mailing Address - Phone:715-568-3612
Mailing Address - Fax:
Practice Address - Street 1:640 JACKSON STREET
Practice Address - Street 2:MC 11503H
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2502
Practice Address - Country:US
Practice Address - Phone:651-254-1025
Practice Address - Fax:651-254-1024
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1073777367A00000X
MN1073777367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39900600Medicaid
MN368240400Medicaid
MN368240400Medicaid
WI39900600Medicaid