Provider Demographics
NPI:1134162654
Name:ROBERTS, JANE B (PAC)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:B
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1038
Mailing Address - Country:US
Mailing Address - Phone:336-375-2300
Mailing Address - Fax:336-375-2313
Practice Address - Street 1:1130 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1038
Practice Address - Country:US
Practice Address - Phone:336-375-2300
Practice Address - Fax:336-375-2313
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101697363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P92969Medicare UPIN
2758910Medicare ID - Type Unspecified