Provider Demographics
NPI:1225537376
Name:ROBERTSON, ANTHONY (PA)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:ROBERTSON
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 1:1401 W NORTH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-3135
Mailing Address - Country:US
Mailing Address - Phone:517-205-2555
Mailing Address - Fax:517-205-0117
Practice Address - Street 1:1401 W NORTH ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-3135
Practice Address - Country:US
Practice Address - Phone:517-205-2555
Practice Address - Fax:517-205-0117
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008569363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIPENDINGMedicaid