Provider Demographics
NPI:1942296082
Name:ROBERTS, MARK ANDREW (PA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANDREW
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 RANDOLPH RD STE 900
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1117
Mailing Address - Country:US
Mailing Address - Phone:704-377-2424
Mailing Address - Fax:704-377-2687
Practice Address - Street 1:1900 RANDOLPH RD STE 900
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1117
Practice Address - Country:US
Practice Address - Phone:704-377-2424
Practice Address - Fax:704-377-2687
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2009-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002314363AM0700X
NC0010-00509363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP00386964OtherRR MEDICARE
NCP00386964OtherRR MEDICARE
NCP27107Medicare UPIN