Provider Demographics
NPI:1558489401
Name:ROBERTSON, SHAWN
Entity Type:Individual
Prefix:MRS
First Name:SHAWN
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 305
Mailing Address - Street 2:
Mailing Address - City:FAY
Mailing Address - State:OK
Mailing Address - Zip Code:73646-9557
Mailing Address - Country:US
Mailing Address - Phone:580-623-7199
Mailing Address - Fax:
Practice Address - Street 1:216 W A ST
Practice Address - Street 2:
Practice Address - City:WATONGA
Practice Address - State:OK
Practice Address - Zip Code:73772-4208
Practice Address - Country:US
Practice Address - Phone:580-623-7199
Practice Address - Fax:580-623-7188
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator