1366474090 NPI number — KATHERINE JO ROBERTS PA-C

Table of content: KATHERINE JO ROBERTS PA-C (NPI 1366474090)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366474090 NPI number — KATHERINE JO ROBERTS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTS
Provider First Name:
KATHERINE
Provider Middle Name:
JO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366474090
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/07/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2234 COLONIAL BLVD
Provider Second Line Business Mailing Address:
ATTN: PAYER CONTRACTING AND RELATIONS
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33907-1412
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-931-7342
Provider Business Mailing Address Fax Number:
239-931-7385

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
39 BARKLEY CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33907-7531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-936-1616
Provider Business Practice Location Address Fax Number:
239-936-0837
Provider Enumeration Date:
07/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA9102961 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1026801 . This is a "STAYWELL (MEDICAID) AND WELLCARE (MEDICARE)." identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P1023220 . This is a "FREEDOM" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: Y09W3 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 398636 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P01283318 . This is a "RAILROAD MCR" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 010879800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5616875 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P961417 . This is a "OPTIMUM" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 010879800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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