Provider Demographics
NPI:1770730053
Name:ROBERTS, EMILY ELIZABETH
Entity type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:ELIZABETH
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:EMILY
Other - Middle Name:ELIZABETH
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3000 OLD CENTRE RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4883
Mailing Address - Country:US
Mailing Address - Phone:269-321-7546
Mailing Address - Fax:269-321-1705
Practice Address - Street 1:3000 OLD CENTRE RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4883
Practice Address - Country:US
Practice Address - Phone:269-321-7546
Practice Address - Fax:269-321-1705
Is Sole Proprietor?:No
Enumeration Date:2008-08-19
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005368363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601005368OtherSTATE LICENSE
MI1770730053Medicaid