Provider Demographics
NPI:1720595457
Name:ROBERTS, JOHN WILLIAM II
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WILLIAM
Last Name:ROBERTS
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 HANSELL SEARS RD
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31535-5720
Mailing Address - Country:US
Mailing Address - Phone:912-592-0765
Mailing Address - Fax:
Practice Address - Street 1:901 18TH ST E
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-3648
Practice Address - Country:US
Practice Address - Phone:229-382-7120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-03
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN230702163W00000X, 367500000X
NH090060-23367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse