Basic Information
| Provider Information | |||||||||
| NPI: | 1538620844 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 PLEASANT ST | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503091406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152416611 | ||||||||
| FaxNumber: | 5152416635 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 PLEASANT ST | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503091406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152416611 | ||||||||
| FaxNumber: | 5152416635 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2019 | ||||||||
| LastUpdateDate: | 09/05/2019 | ||||||||
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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 | 163WE0003X | 102334 | IA | N | Nursing Service Providers | Registered Nurse | Emergency | 363LP0200X | C155676 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.