Provider Demographics
NPI:1548413164
Name:ROBERTS, ANNE M (PA)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:M
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4411 QUAIL LN
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68801-8515
Mailing Address - Country:US
Mailing Address - Phone:308-380-4876
Mailing Address - Fax:
Practice Address - Street 1:4600 38TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:NE
Practice Address - Zip Code:68601-1664
Practice Address - Country:US
Practice Address - Phone:402-564-7118
Practice Address - Fax:402-562-3378
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1407363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE096576008Medicare PIN