Provider Demographics
NPI:1205859857
Name:ROBERTS, THOMAS G (PA-C)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:G
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 1:12671 EMERALD COAST PKWY W UNIT 215
Mailing Address - Street 2:UNIT 215
Mailing Address - City:MIRAMAR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32550-8304
Mailing Address - Country:US
Mailing Address - Phone:850-424-7170
Mailing Address - Fax:850-424-7169
Practice Address - Street 1:12671 EMERALD COAST PKWY W
Practice Address - Street 2:UNIT 215
Practice Address - City:MIRAMAR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32550-8300
Practice Address - Country:US
Practice Address - Phone:850-424-7170
Practice Address - Fax:850-424-7169
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 3482363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA0003482OtherSTATE LICENSE NUMBER
FL1997Medicare UPIN