Provider Demographics
NPI:1043603400
Name:ROBERSON, DESHAWN MICHAEL
Entity Type:Individual
Prefix:MR
First Name:DESHAWN
Middle Name:MICHAEL
Last Name:ROBERSON
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 1:10515 BALBOA BLVD
Mailing Address - Street 2:SUITE 285
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-6343
Mailing Address - Country:US
Mailing Address - Phone:619-820-7062
Mailing Address - Fax:
Practice Address - Street 1:10515 BALBOA BLVD
Practice Address - Street 2:SUITE 285
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-6343
Practice Address - Country:US
Practice Address - Phone:619-820-7062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-10
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA390200000X
CA54384363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program