Provider Demographics
NPI:1164033353
Name:ROBERTS, TYLER (PA-C)
Entity Type:Individual
Prefix:
First Name:TYLER
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 1:15 EXCHANGE DR
Mailing Address - Street 2:
Mailing Address - City:LUGOFF
Mailing Address - State:SC
Mailing Address - Zip Code:29078-9198
Mailing Address - Country:US
Mailing Address - Phone:803-670-8238
Mailing Address - Fax:
Practice Address - Street 1:15 EXCHANGE DR
Practice Address - Street 2:
Practice Address - City:LUGOFF
Practice Address - State:SC
Practice Address - Zip Code:29078-9198
Practice Address - Country:US
Practice Address - Phone:803-670-8238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-12
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4796363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant