Provider Demographics
NPI:1790379261
Name:ROTH, ELIZABETH (DNP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:WEHRHEIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:4630 BEACON HILL RD
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-2705
Mailing Address - Country:US
Mailing Address - Phone:262-370-5689
Mailing Address - Fax:
Practice Address - Street 1:715 S 8TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-1210
Practice Address - Country:US
Practice Address - Phone:612-873-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-25
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2029539163W00000X
MN8071363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse