Provider Demographics
NPI:1083015382
Name:ROBERTS, DIRK E (RNFA, FNP-C)
Entity Type:Individual
Prefix:
First Name:DIRK
Middle Name:E
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:RNFA, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 MAPLE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-1976
Mailing Address - Country:US
Mailing Address - Phone:573-756-7779
Mailing Address - Fax:573-756-6914
Practice Address - Street 1:606 MAPLE VALLEY DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1976
Practice Address - Country:US
Practice Address - Phone:573-756-7779
Practice Address - Fax:573-756-6914
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-06
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015025676363LF0000X
MO151527163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse