Provider Demographics
NPI:1114405438
Name:ROBERTS, NATHAN (PA-C)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:M
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:PO BOX 3007
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47202-3007
Mailing Address - Country:US
Mailing Address - Phone:812-379-4441
Mailing Address - Fax:
Practice Address - Street 1:2400 17TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-5351
Practice Address - Country:US
Practice Address - Phone:812-379-4441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN100024878A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant