Provider Demographics
NPI:1346248564
Name:ROBERSON, CARRIE RUTH (PA)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:RUTH
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 S BEACON BLVD
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-2654
Mailing Address - Country:US
Mailing Address - Phone:616-344-1033
Mailing Address - Fax:
Practice Address - Street 1:1600 S BEACON BLVD
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2654
Practice Address - Country:US
Practice Address - Phone:616-344-1033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003155363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM74460310Medicare PIN
MI0N10760 002Medicare ID - Type Unspecified
S98029Medicare UPIN