Provider Demographics
NPI:1902200355
Name:ROBERTS, CALEY (PA)
Entity Type:Individual
Prefix:
First Name:CALEY
Middle Name:
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 1:201 ALBERT AVE
Mailing Address - Street 2:
Mailing Address - City:SCOTT CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67871
Mailing Address - Country:US
Mailing Address - Phone:620-872-2187
Mailing Address - Fax:620-872-7193
Practice Address - Street 1:201 ALBERT AVE
Practice Address - Street 2:
Practice Address - City:SCOTT CITY
Practice Address - State:KS
Practice Address - Zip Code:67871
Practice Address - Country:US
Practice Address - Phone:620-872-2187
Practice Address - Fax:620-872-7193
Is Sole Proprietor?:No
Enumeration Date:2014-10-14
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-01750363AM0700X
KS1501750363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201106490AMedicaid