Basic Information
| Provider Information | |||||||||
| NPI: | 1477074565 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | ALEXANDER | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 444 BUTTERFLY GARDENS DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432153427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6149380167 | ||||||||
| FaxNumber: | 6149380170 | ||||||||
| Practice Location | |||||||||
| Address1: | 1002 WISHARD BLVD STE 4110 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462022872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143557505 | ||||||||
| FaxNumber: | 6143557545 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2017 | ||||||||
| LastUpdateDate: | 01/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 71010582A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | APRN.CNP020996 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 0230411 | 05 | OH | MEDICAID |