Provider Demographics
NPI:1881312387
Name:ROBERTS, REBECCA JANE
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:JANE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 COUNTY ROAD 150
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76240-0485
Mailing Address - Country:US
Mailing Address - Phone:940-595-1384
Mailing Address - Fax:
Practice Address - Street 1:1023 LIPSCOMB ST STE 200
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3102
Practice Address - Country:US
Practice Address - Phone:972-544-6600
Practice Address - Fax:972-544-6604
Is Sole Proprietor?:No
Enumeration Date:2022-08-19
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXPA18329363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program