Provider Demographics
NPI:1922047414
Name:ROBERTS, STANLEY L (PA-C)
Entity Type:Individual
Prefix:MR
First Name:STANLEY
Middle Name:L
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 1:510 MELTON HILL DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:TN
Mailing Address - Zip Code:37716-7107
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:510 MELTON HILL DR
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:TN
Practice Address - Zip Code:37716-7107
Practice Address - Country:US
Practice Address - Phone:865-457-4027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMR0575754363A00000X
TNPA00015363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4069076OtherBLUE CROSS
TN4069076OtherBLUE CROSS