Provider Demographics
NPI:1376636829
Name:ROBERTSON, RICHARD C (PA-C)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:C
Last Name:ROBERTSON
Suffix:
Gender:M
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 1:9 CAREY RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-7880
Mailing Address - Country:US
Mailing Address - Phone:518-761-0300
Mailing Address - Fax:518-824-2388
Practice Address - Street 1:3767 MAIN ST
Practice Address - Street 2:
Practice Address - City:WARRENSBURG
Practice Address - State:NY
Practice Address - Zip Code:12885-1890
Practice Address - Country:US
Practice Address - Phone:518-623-2844
Practice Address - Fax:518-623-3416
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004252363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01540165Medicaid
NYR86507Medicare UPIN
NYAA0798Medicare PIN
NY4108260001Medicare NSC