Provider Demographics
NPI:1134290794
Name:ROBERTS, DOUGLAS M (CRNA)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:M
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 603366
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3366
Mailing Address - Country:US
Mailing Address - Phone:240-566-1600
Mailing Address - Fax:240-566-1605
Practice Address - Street 1:509 BILTMORE AVE
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28801-4601
Practice Address - Country:US
Practice Address - Phone:828-213-2325
Practice Address - Fax:828-213-2311
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1671100163W00000X
CA050829367500000X
NC167110367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2617987CMedicare PIN
NC8051301Medicaid