Provider Demographics
NPI:1366474090
Name:ROBERTS, KATHERINE JO (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:JO
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING AND RELATIONS
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:39 BARKLEY CIR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-7531
Practice Address - Country:US
Practice Address - Phone:239-936-1616
Practice Address - Fax:239-936-0837
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102961363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1026801OtherSTAYWELL (MEDICAID) AND WELLCARE (MEDICARE).
FLP1023220OtherFREEDOM
FLY09W3OtherBCBS
FL398636OtherAVMED
FLP01283318OtherRAILROAD MCR
FL010879800Medicaid
FL5616875OtherAETNA
FLP961417OtherOPTIMUM
FLU5768ZMedicare UPIN
FLU5768WMedicare PIN