Provider Demographics
NPI:1093775553
Name:ROBERTS, ROBERT L (CRNA)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:L
Last Name:ROBERTS
Suffix:
Gender:M
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 840853
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0853
Mailing Address - Country:US
Mailing Address - Phone:972-233-1999
Mailing Address - Fax:972-233-3666
Practice Address - Street 1:3901 W 15TH ST
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075
Practice Address - Country:US
Practice Address - Phone:972-519-1115
Practice Address - Fax:972-519-1456
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-27
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX515758367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00238524OtherRAILROAD
TX119917602Medicaid
TX119917606Medicaid
TX81006UOtherBCBS
TX119917604Medicaid
TX119917605Medicaid
TX89133KMedicare PIN
TX88953KMedicare PIN
TX119917606Medicaid
TX81006UOtherBCBS
TX119917602Medicaid
TX85102KMedicare PIN