Provider Demographics
NPI:1528392941
Name:ROBERTS, MARILYN MARGARET (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:MARGARET
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:CHEYENNE RIVER HEALTH CENTER
Mailing Address - Street 2:24276 166TH ST, AIRPORT RD
Mailing Address - City:EAGLE BUTTE
Mailing Address - State:SD
Mailing Address - Zip Code:57625-1012
Mailing Address - Country:US
Mailing Address - Phone:605-964-7724
Mailing Address - Fax:
Practice Address - Street 1:CRHC
Practice Address - Street 2:24276 166TH ST, AIRPORT RD
Practice Address - City:EAGLE BUTTE
Practice Address - State:SD
Practice Address - Zip Code:57625-1012
Practice Address - Country:US
Practice Address - Phone:605-964-7724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-01
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20483363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical