Provider Demographics
NPI:1437259926
Name:HERBST, ROBERTA L (PA-C)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:L
Last Name:HERBST
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 1:6227 FRANKFORT HWY
Mailing Address - Street 2:
Mailing Address - City:BENZONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49616-9654
Mailing Address - Country:US
Mailing Address - Phone:231-882-9661
Mailing Address - Fax:231-882-9616
Practice Address - Street 1:1975 STIRLING DR
Practice Address - Street 2:
Practice Address - City:INTERLOCHEN
Practice Address - State:MI
Practice Address - Zip Code:49643-9264
Practice Address - Country:US
Practice Address - Phone:231-275-7965
Practice Address - Fax:231-275-7969
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002897363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMH1108011OtherDEA