Provider Demographics
NPI:1801099874
Name:RODERICK, ELIZABETH (APRN-BC)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:
Last Name:RODERICK
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 FARAON ST STE 220
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-3800
Mailing Address - Country:US
Mailing Address - Phone:816-271-8131
Mailing Address - Fax:816-271-8132
Practice Address - Street 1:5301 FARAON ST STE 220
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-3800
Practice Address - Country:US
Practice Address - Phone:816-271-8131
Practice Address - Fax:816-271-8132
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO138383363LA2200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200672230AMedicaid
MO428451702Medicaid
MO1801099874Medicaid
MO428451702Medicaid