Provider Demographics
NPI:1346757481
Name:ROBERTS, JEFFERY W (CRNA)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:W
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8516 LAIRD ST
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32408-7820
Mailing Address - Country:US
Mailing Address - Phone:229-891-6119
Mailing Address - Fax:
Practice Address - Street 1:3131 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6925
Practice Address - Country:US
Practice Address - Phone:229-985-3420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-10
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN215734367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered