Provider Demographics
NPI:1083772156
Name:ROBERTS, MARY K (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:K
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1143
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-1143
Mailing Address - Country:US
Mailing Address - Phone:304-487-3559
Mailing Address - Fax:304-487-7928
Practice Address - Street 1:109 MORRISON DR
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2322
Practice Address - Country:US
Practice Address - Phone:304-487-3559
Practice Address - Fax:304-487-7928
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19857367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0066651000Medicaid
0801011Medicare ID - Type Unspecified