Provider Demographics
NPI:1225255987
Name:SHORT, ROBERTA RAE (ETC)
Entity Type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:RAE
Last Name:SHORT
Suffix:
Gender:F
Credentials:ETC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PHS INDIAN HOSPITAL
Mailing Address - Street 2:12033 AGENCY RD
Mailing Address - City:PARKER
Mailing Address - State:AR
Mailing Address - Zip Code:85344-9703
Mailing Address - Country:US
Mailing Address - Phone:928-662-4718
Mailing Address - Fax:
Practice Address - Street 1:12033 AGENCY RD
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344-7718
Practice Address - Country:US
Practice Address - Phone:928-662-4718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant