Provider Demographics
NPI:1205332053
Name:ROBERTS, NICHOLAS RYAN (MD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:RYAN
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 1:1501 KINGS HIGHWAY
Mailing Address - Street 2:EMERGENCY MEDICINE
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71130
Mailing Address - Country:US
Mailing Address - Phone:318-626-1034
Mailing Address - Fax:
Practice Address - Street 1:1501 KINGS HIGHWAY
Practice Address - Street 2:EMERGENCY MEDICINE
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71130
Practice Address - Country:US
Practice Address - Phone:318-626-1034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-02
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA322986207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine