Provider Demographics
NPI:1194463935
Name:ROBERTSON, JOHN (LAT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 LARKSPUR LN
Mailing Address - Street 2:
Mailing Address - City:CLEBURNE
Mailing Address - State:TX
Mailing Address - Zip Code:76033-4672
Mailing Address - Country:US
Mailing Address - Phone:254-337-0986
Mailing Address - Fax:
Practice Address - Street 1:1102 LARKSPUR LN
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-4672
Practice Address - Country:US
Practice Address - Phone:254-337-0986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-23
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT13002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAT1300OtherTEXAS DEPARTMENT OF HEALTH