Provider Demographics
NPI:1750429395
Name:ROERS, NAOMI AUTUMN (PA-C)
Entity type:Individual
Prefix:
First Name:NAOMI
Middle Name:AUTUMN
Last Name:ROERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7373 FRANCE AVE S STE 202
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-4551
Mailing Address - Country:US
Mailing Address - Phone:952-428-0001
Mailing Address - Fax:
Practice Address - Street 1:7373 FRANCE AVE S STE 202
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4551
Practice Address - Country:US
Practice Address - Phone:952-428-0001
Practice Address - Fax:952-428-0095
Is Sole Proprietor?:No
Enumeration Date:2007-02-04
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11259363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN11259OtherSTATE LICENSE