Provider Demographics
NPI:1922108430
Name:ROBERTS, CAROLYN D (CRNA)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:D
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 RUTH ST N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55119-4323
Mailing Address - Country:US
Mailing Address - Phone:651-735-0501
Mailing Address - Fax:651-735-1870
Practice Address - Street 1:333 SMITH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2344
Practice Address - Country:US
Practice Address - Phone:651-735-0501
Practice Address - Fax:651-251-8050
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR0762665367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN53G41ROOtherBCBS