Provider Demographics
NPI:1932735800
Name:ROBERTS, SHAUN PETER (IDC)
Entity Type:Individual
Prefix:
First Name:SHAUN
Middle Name:PETER
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3D DEN :BN 3MLG
Mailing Address - Street 2:UNIT 38450 FPO AP 96373 8450
Mailing Address - City:OKINAWA
Mailing Address - State:CAMP FOSTER
Mailing Address - Zip Code:96373
Mailing Address - Country:JP
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3D DEN :BN 3MLG
Practice Address - Street 2:UNIT 38450 FPO AP 96373 8450
Practice Address - City:OKINAWA
Practice Address - State:CAMP FOSTER
Practice Address - Zip Code:96373
Practice Address - Country:JP
Practice Address - Phone:098-954-7539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-23
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman