Provider Demographics
NPI:1134143332
Name:ROBERTSON, ROBERT RAY (APRN)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:RAY
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:BOB
Other - Middle Name:
Other - Last Name:ROBERTSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 6369
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TX
Mailing Address - Zip Code:75461-6245
Mailing Address - Country:US
Mailing Address - Phone:903-782-9500
Mailing Address - Fax:903-782-9550
Practice Address - Street 1:3605 N.E. LOOP 286
Practice Address - Street 2:SUITE 2000
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75460-5085
Practice Address - Country:US
Practice Address - Phone:903-782-9500
Practice Address - Fax:903-782-9550
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX569790364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8Y8876OtherBLUE CROSS BLUE SHIELD
TX75-2803871OtherTAX IDENTIFICATION NUMBER
TX062572502Medicaid
TX8F8672Medicare PIN