Basic Information
| Provider Information | |||||||||
| NPI: | 1710238308 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROBERTSON | ||||||||
| FirstName: | LORA | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1117 E HALLANDALE BEACH BLVD | ||||||||
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| City: | HALLANDALE BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330094488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544578771 | ||||||||
| FaxNumber: | 9542664006 | ||||||||
| Practice Location | |||||||||
| Address1: | 593 EDDY ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029034923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017939166 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2012 | ||||||||
| LastUpdateDate: | 06/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 9106820 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA01203 | RI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.