Provider Demographics
NPI:1134396518
Name:ROBERTS, KATIE RENEE (PA-C)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:RENEE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:RENEE
Other - Last Name:GRAHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:647 N BROAD STREET EXT
Mailing Address - Street 2:STE 201
Mailing Address - City:GROVE CITY
Mailing Address - State:PA
Mailing Address - Zip Code:16127-4604
Mailing Address - Country:US
Mailing Address - Phone:724-264-4190
Mailing Address - Fax:724-264-4194
Practice Address - Street 1:647 N BROAD STREET EXT
Practice Address - Street 2:STE 201
Practice Address - City:GROVE CITY
Practice Address - State:PA
Practice Address - Zip Code:16127-4604
Practice Address - Country:US
Practice Address - Phone:724-264-4190
Practice Address - Fax:724-264-4194
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2021-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052721363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
11976922OtherCAQH
PA1J4395Medicaid