Basic Information
| Provider Information | |||||||||
| NPI: | 1346757481 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | JEFFERY | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8516 LAIRD ST | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324087820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2298916119 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3131 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317686925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2299853420 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2018 | ||||||||
| LastUpdateDate: | 01/12/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN215734 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.