Basic Information
| Provider Information | |||||||||
| NPI: | 1942342159 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | TISA | ||||||||
| MiddleName: | O | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2723 | ||||||||
| Address2: | |||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278022723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2522126802 | ||||||||
| FaxNumber: | 2522123497 | ||||||||
| Practice Location | |||||||||
| Address1: | 1041 NOELL LN | ||||||||
| Address2: | MEDICAL PLAZA B | ||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278042058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2523168205 | ||||||||
| FaxNumber: | 2529623451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2007 | ||||||||
| LastUpdateDate: | 10/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2006-01513 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.