Provider Demographics
NPI:1740511831
Name:ROTH, SHOSTY SUE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:SHOSTY
Middle Name:SUE
Last Name:ROTH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHOSTY
Other - Middle Name:SUE
Other - Last Name:HEYBLOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4119 GRANT VALLEY RD NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-5370
Mailing Address - Country:US
Mailing Address - Phone:218-403-1260
Mailing Address - Fax:
Practice Address - Street 1:332 W SUPERIOR ST
Practice Address - Street 2:SUITE 300
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1808
Practice Address - Country:US
Practice Address - Phone:218-722-4379
Practice Address - Fax:218-722-4333
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-29
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN107422084P0800X, 363A00000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical