Provider Demographics
NPI:1558890848
Name:ROTH, BOBBI LEE (FNP)
Entity Type:Individual
Prefix:
First Name:BOBBI LEE
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 NW LOVEJOY ST
Mailing Address - Street 2:STE 505
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-5103
Mailing Address - Country:US
Mailing Address - Phone:503-242-9850
Mailing Address - Fax:503-226-3539
Practice Address - Street 1:19250 SW 65TH AVE STE 110
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-7707
Practice Address - Country:US
Practice Address - Phone:503-692-1805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2017-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201702881NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily