Provider Demographics
NPI:1932693504
Name:ROBERTSON, JONATHAN MICHAEL (APRN)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MICHAEL
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 N RACE ST
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-3483
Mailing Address - Country:US
Mailing Address - Phone:270-651-4444
Mailing Address - Fax:270-651-4892
Practice Address - Street 1:1301 N RACE ST
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-3483
Practice Address - Country:US
Practice Address - Phone:270-651-4444
Practice Address - Fax:270-651-4892
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN31293363L00000X
KY3012416363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100538040Medicaid
KY3012416OtherAPRN STATE LICENSE