Provider Demographics
NPI:1497711105
Name:ROBERTS, MARK D (PA-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 HEWITT DR STE 203
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-8834
Mailing Address - Country:US
Mailing Address - Phone:254-666-3627
Mailing Address - Fax:254-732-6125
Practice Address - Street 1:1201 HEWITT DR STE 203
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-8834
Practice Address - Country:US
Practice Address - Phone:254-666-3627
Practice Address - Fax:254-732-6125
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02376363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX191296602Medicaid
TX8Y9746OtherBCBS
TX191296603Medicaid
TX261742781OtherTX ID
TX8Y2805OtherBLUE CROSS BLUE SHIELD OF TEXAS
TX8L10914OtherMEDICARE
TX191296601Medicaid
TX8Y2805OtherBLUE CROSS BLUE SHIELD OF TEXAS
TX$$$$$$$$$OtherTRICARE
TX8K1874Medicare PIN
TX191296601Medicaid
TX00Z020Medicare PIN