Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363L00000X | Nurse Practitioner | 4704219864 | MI |
Y | 363LF0000X | Nurse Practitioner - Family Medicine | 4704219864 | MI |
NPI | 1003269895 |
---|---|
Provider Name | Jason Roberts |
First Address | Rockford, MI 49341-1130 |
Second Address | Rockford, MI 49341-1130 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/07/2016 |
Last Update Date | 11/02/2019 |