Basic Information
| Provider Information | |||||||||
| NPI: | 1437259926 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERBST | ||||||||
| FirstName: | ROBERTA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6227 FRANKFORT HWY | ||||||||
| Address2: | |||||||||
| City: | BENZONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496169654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2318829661 | ||||||||
| FaxNumber: | 2318829616 | ||||||||
| Practice Location | |||||||||
| Address1: | 1975 STIRLING DR | ||||||||
| Address2: | |||||||||
| City: | INTERLOCHEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496439264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2312757965 | ||||||||
| FaxNumber: | 2312757969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601002897 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | MH1108011 | 01 | MI | DEA | OTHER |