Provider Demographics
NPI:1942351333
Name:ROTH, HEATHER A (NP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:A
Last Name:ROTH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 20092
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82003-7002
Mailing Address - Country:US
Mailing Address - Phone:307-630-4729
Mailing Address - Fax:
Practice Address - Street 1:2500 DELL RANGE BLVD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-5273
Practice Address - Country:US
Practice Address - Phone:307-630-4729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA259049363L00000X
CO0990361363L00000X
NH057094-21363L00000X
NH057094-23-03363L00000X
WY52020363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAQ62247Medicare UPIN
MAQ62247Medicare UPIN