Provider Demographics
NPI:1508956202
Name:ROBERTS, BRIAN K (PA-C)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:K
Last Name:ROBERTS
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 1:3400 SPRUCE STREET
Mailing Address - Street 2:4 SILVERSTEIN
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4206
Mailing Address - Country:US
Mailing Address - Phone:215-615-4949
Mailing Address - Fax:
Practice Address - Street 1:3400 SPRUCE STREET
Practice Address - Street 2:4 SILVERSTEIN
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:215-615-4949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051149363AM0700X
NJ25MP00065900363AS0400X
NJMP000659363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical