Provider Demographics
NPI:1336576677
Name:ROBERTS, ERIC N (PAC)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:N
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 CHAD ST
Mailing Address - Street 2:
Mailing Address - City:EVARTS
Mailing Address - State:KY
Mailing Address - Zip Code:40828-8200
Mailing Address - Country:US
Mailing Address - Phone:606-837-2108
Mailing Address - Fax:606-837-9389
Practice Address - Street 1:101 CHAD ST
Practice Address - Street 2:CLOVER FORK CLINIC
Practice Address - City:EVARTS
Practice Address - State:KY
Practice Address - Zip Code:40828-8200
Practice Address - Country:US
Practice Address - Phone:606-837-2108
Practice Address - Fax:606-837-9389
Is Sole Proprietor?:No
Enumeration Date:2013-10-01
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA-1849363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100273510Medicaid
KYK093610Medicare PIN