Provider Demographics
NPI:1104979616
Name:ROTH, RANDY A (CRNA)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:A
Last Name:ROTH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:559 WEDGE CT
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49036-8859
Mailing Address - Country:US
Mailing Address - Phone:517-238-2701
Mailing Address - Fax:
Practice Address - Street 1:274 E CHICAGO ST
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MI
Practice Address - Zip Code:49036-2041
Practice Address - Country:US
Practice Address - Phone:517-279-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704153363367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4580900Medicaid