Provider Demographics
NPI:1982247383
Name:ROBERTS, VICTORIA ANDERSON (PA-C)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:ANDERSON
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 ELLETT RD
Mailing Address - Street 2:
Mailing Address - City:CHAPIN
Mailing Address - State:SC
Mailing Address - Zip Code:29036-8604
Mailing Address - Country:US
Mailing Address - Phone:803-941-8095
Mailing Address - Fax:
Practice Address - Street 1:104 ELLETT RD
Practice Address - Street 2:
Practice Address - City:CHAPIN
Practice Address - State:SC
Practice Address - Zip Code:29036-8604
Practice Address - Country:US
Practice Address - Phone:803-941-8095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-18
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4238PAMedicaid