Provider Demographics
NPI:1912072265
Name:ROBERTS, MARTHA L (RN PC NP)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:L
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:RN PC NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 WATERHOUSE RD
Mailing Address - Street 2:#3
Mailing Address - City:BOURNE
Mailing Address - State:MA
Mailing Address - Zip Code:02532-3897
Mailing Address - Country:US
Mailing Address - Phone:508-759-7279
Mailing Address - Fax:508-759-6942
Practice Address - Street 1:16 WATERHOUSE RD
Practice Address - Street 2:#3
Practice Address - City:BOURNE
Practice Address - State:MA
Practice Address - Zip Code:02532-3897
Practice Address - Country:US
Practice Address - Phone:508-759-7279
Practice Address - Fax:508-759-6942
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA161304363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAFA NS0526Medicare ID - Type Unspecified
MAP57435Medicare UPIN