Provider Demographics
NPI:1629546072
Name:ROBERSON, ANDRE
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:
Last Name:ROBERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 EVERGREEN LN N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-4834
Mailing Address - Country:US
Mailing Address - Phone:763-200-7441
Mailing Address - Fax:
Practice Address - Street 1:1110 EVERGREEN LN N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-4834
Practice Address - Country:US
Practice Address - Phone:763-200-7441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-04
Last Update Date:2018-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion