Provider Demographics
NPI:1295878429
Name:ROBERTS, SHAWN ADELE (MS FNP)
Entity type:Individual
Prefix:MS
First Name:SHAWN
Middle Name:ADELE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:MS FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22626 LAKE HILL DR.
Mailing Address - Street 2:
Mailing Address - City:CHUGIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99567
Mailing Address - Country:US
Mailing Address - Phone:907-440-6450
Mailing Address - Fax:907-688-8453
Practice Address - Street 1:950 E BOGARD RD
Practice Address - Street 2:SUITE 103
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7184
Practice Address - Country:US
Practice Address - Phone:907-352-2880
Practice Address - Fax:907-352-2885
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK166363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK0166-02Medicaid
AK0166-02Medicaid