Provider Demographics
NPI:1568493757
Name:ROBERTS, JOHN RUSSELL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:RUSSELL
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:PO BOX 4207
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75606-4207
Mailing Address - Country:US
Mailing Address - Phone:903-315-5520
Mailing Address - Fax:
Practice Address - Street 1:409 N 6TH ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-6536
Practice Address - Country:US
Practice Address - Phone:903-315-5520
Practice Address - Fax:903-663-6371
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03743363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX81742OtherBC/BS
TX5536069OtherAETNA
TX81742OtherBC/BS