Provider Demographics
NPI:1073886909
Name:ROBERTS, SHERI KAE (PA)
Entity Type:Individual
Prefix:
First Name:SHERI
Middle Name:KAE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 LIELMANIS AVE
Mailing Address - Street 2:
Mailing Address - City:HURLBURT FIELD
Mailing Address - State:FL
Mailing Address - Zip Code:32544-5613
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:113 LIELMANIS AVE
Practice Address - Street 2:
Practice Address - City:HURLBURT FIELD
Practice Address - State:FL
Practice Address - Zip Code:32544-5613
Practice Address - Country:US
Practice Address - Phone:850-881-1020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-23
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025053363A00000X
390200000X, 1710I1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians
Provider Identifiers
StateIdentifier IDID TypeIssuer
1073886909OtherMILITARY