Provider Demographics
NPI:1932252665
Name:ROOSTA, ROYA (CRNA)
Entity Type:Individual
Prefix:
First Name:ROYA
Middle Name:
Last Name:ROOSTA
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 1:1101 W UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-1863
Mailing Address - Country:US
Mailing Address - Phone:248-652-5354
Mailing Address - Fax:248-652-5861
Practice Address - Street 1:1101 W UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-1863
Practice Address - Country:US
Practice Address - Phone:248-652-5354
Practice Address - Fax:248-652-5861
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704206586367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4705433Medicaid
11905112OtherCAQH
MI430F364550OtherBCBS
MI0F36455210Medicare ID - Type Unspecified