Provider Demographics
NPI:1457312217
Name:RICCI, ROXANNE VIDA (NP)
Entity Type:Individual
Prefix:
First Name:ROXANNE
Middle Name:VIDA
Last Name:RICCI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ROXANNE
Other - Middle Name:VIDA
Other - Last Name:SYSE, ERICKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:MR 10809
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-0043
Mailing Address - Country:US
Mailing Address - Phone:612-262-4813
Mailing Address - Fax:612-262-4194
Practice Address - Street 1:800 E 28TH ST
Practice Address - Street 2:SUITE H2100
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-3723
Practice Address - Country:US
Practice Address - Phone:612-775-3030
Practice Address - Fax:612-863-1681
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1516363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q29611Medicare UPIN