Provider Demographics
NPI:1932634706
Name:ROBERTS, JOEL (MD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1806 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-2473
Mailing Address - Country:US
Mailing Address - Phone:509-452-4520
Mailing Address - Fax:
Practice Address - Street 1:1806 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-2473
Practice Address - Country:US
Practice Address - Phone:509-452-4520
Practice Address - Fax:509-452-5224
Is Sole Proprietor?:No
Enumeration Date:2017-04-28
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAML60756123207Q00000X
WAMD60963500207Q00000X
WAMD60963491207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2080268Medicaid