Healthcare Provider Details

I. General information

NPI: 1336426626
Provider Name (Legal Business Name): LINDSEY KOROTASH ROTH CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2011
Last Update Date: 12/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE
BURLINGTON VT
05401-1473
US

IV. Provider business mailing address

30 S CAYUGA RD
WILLIAMSVILLE NY
14221-6728
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-2415
  • Fax: 802-847-5324
Mailing address:
  • Phone: 716-632-1088
  • Fax: 716-632-7842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number584542
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number101.0134235
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: