Provider Demographics
NPI:1699399246
Name:ROBERTS, RONALD
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:ROBERTS
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 1:42 SUGARBUSH CT
Mailing Address - Street 2:
Mailing Address - City:OAKLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94561-2365
Mailing Address - Country:US
Mailing Address - Phone:925-586-3752
Mailing Address - Fax:
Practice Address - Street 1:42 SUGARBUSH CT
Practice Address - Street 2:
Practice Address - City:OAKLEY
Practice Address - State:CA
Practice Address - Zip Code:94561-2365
Practice Address - Country:US
Practice Address - Phone:925-586-3752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-29
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer