Provider Demographics
NPI:1912908500
Name:ROBERTSON, L MICHELLE (PA)
Entity Type:Individual
Prefix:
First Name:L
Middle Name:MICHELLE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:MICHELLE
Other - Last Name:ROBERTSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:6475 S YALE AVE
Mailing Address - Street 2:STE. 301
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-7816
Mailing Address - Country:US
Mailing Address - Phone:918-494-9300
Mailing Address - Fax:918-494-9324
Practice Address - Street 1:6475 S YALE AVE
Practice Address - Street 2:STE. 301
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-7816
Practice Address - Country:US
Practice Address - Phone:918-494-9300
Practice Address - Fax:918-494-9324
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1344363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP77789Medicare UPIN