Provider Demographics
NPI:1073619409
Name:ROBERTSON, MYA D (NP)
Entity Type:Individual
Prefix:
First Name:MYA
Middle Name:D
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 W TAFT RD
Mailing Address - Street 2:STE 2E
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-3807
Mailing Address - Country:US
Mailing Address - Phone:315-634-3399
Mailing Address - Fax:
Practice Address - Street 1:5100 W TAFT RD
Practice Address - Street 2:STE 2E
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-3807
Practice Address - Country:US
Practice Address - Phone:315-634-3399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY508474363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02730523Medicaid
NYQ37916Medicare UPIN
NYRA5928Medicare ID - Type Unspecified