Provider Demographics
NPI:1265852909
Name:ROBERTS, WHITNEY ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:WHITNEY
Middle Name:ANN
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:WHITNEY
Other - Middle Name:ANN
Other - Last Name:EGBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:465 MCKENNA DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-2143
Mailing Address - Country:US
Mailing Address - Phone:208-580-2689
Mailing Address - Fax:208-580-9002
Practice Address - Street 1:465 MCKENNA DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-2143
Practice Address - Country:US
Practice Address - Phone:208-580-2689
Practice Address - Fax:208-580-9002
Is Sole Proprietor?:No
Enumeration Date:2014-04-21
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1122363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant