Provider Demographics
NPI:1376586099
Name:ROTAR, SCOTT J (CRNA)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:J
Last Name:ROTAR
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 1:240 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:WOODRUFF
Mailing Address - State:WI
Mailing Address - Zip Code:54568-0470
Mailing Address - Country:US
Mailing Address - Phone:715-892-4835
Mailing Address - Fax:
Practice Address - Street 1:240 MAPLE ST
Practice Address - Street 2:
Practice Address - City:WOODRUFF
Practice Address - State:WI
Practice Address - Zip Code:54568-0470
Practice Address - Country:US
Practice Address - Phone:715-892-4835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI127205-030163W00000X
WI051474367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43401700Medicaid
WI000321198Medicare PIN
WIP13021Medicare UPIN