Provider Demographics
NPI:1083275325
Name:ROBERTS, EMMIE LOU (PA-C)
Entity Type:Individual
Prefix:
First Name:EMMIE LOU
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 ARMISTICE BLVD
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-3242
Mailing Address - Country:US
Mailing Address - Phone:401-725-4100
Mailing Address - Fax:
Practice Address - Street 1:209 ARMISTICE BLVD
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-3242
Practice Address - Country:US
Practice Address - Phone:401-725-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-26
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA01167363AM0700X, 363A00000X
MAPA7338363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical