Provider Demographics
NPI:1558031047
Name:ROBERTS, ASHLEY RACHELLE (PA)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:RACHELLE
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 1:1705 W LAKEVIEW DR APT 2
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-2168
Mailing Address - Country:US
Mailing Address - Phone:423-342-9892
Mailing Address - Fax:
Practice Address - Street 1:2050 MEADOWVIEW PKWY
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-7475
Practice Address - Country:US
Practice Address - Phone:423-230-5613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA0000004615363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant