1295878429 NPI number — MS. SHAWN ADELE ROBERTS MS FNP

Table of content: MS. SHAWN ADELE ROBERTS MS FNP (NPI 1295878429)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295878429 NPI number — MS. SHAWN ADELE ROBERTS MS FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTS
Provider First Name:
SHAWN
Provider Middle Name:
ADELE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MS FNP
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:
1295878429
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/05/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22626 LAKE HILL DR.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHUGIAK
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99567
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-440-6450
Provider Business Mailing Address Fax Number:
907-688-8453

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
950 E BOGARD RD
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
WASILLA
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99654-7184
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-352-2880
Provider Business Practice Location Address Fax Number:
907-352-2885
Provider Enumeration Date:
02/15/2007

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: 363LF0000X , with the licence number:  166 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0166-02 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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