Provider Demographics
NPI:1033700919
Name:ROBERTSON, JOHN TYLER
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:TYLER
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 E SIOUX LN
Mailing Address - Street 2:
Mailing Address - City:ROMNEY
Mailing Address - State:WV
Mailing Address - Zip Code:26757-1429
Mailing Address - Country:US
Mailing Address - Phone:304-822-0869
Mailing Address - Fax:
Practice Address - Street 1:160 E SIOUX LN
Practice Address - Street 2:
Practice Address - City:ROMNEY
Practice Address - State:WV
Practice Address - Zip Code:26757-1429
Practice Address - Country:US
Practice Address - Phone:304-822-0869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant