Provider Demographics
NPI:1225024680
Name:ROBERTS, SHELDON J (PA)
Entity Type:Individual
Prefix:MR
First Name:SHELDON
Middle Name:J
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 E 23RD ST
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-5307
Mailing Address - Country:US
Mailing Address - Phone:850-215-8999
Mailing Address - Fax:850-215-8681
Practice Address - Street 1:509 E 23RD ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-5307
Practice Address - Country:US
Practice Address - Phone:850-215-8999
Practice Address - Fax:850-215-8681
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104118363A00000X
AZ1863363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ398661Medicaid
P08500Medicare UPIN
79214Medicare ID - Type UnspecifiedGHR MEDICARE NUMBER