Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207ND0900X | Dermatopathologist | E8856 | TX |
NPI | 1578565859 |
---|---|
Provider Name | Larry C Roberts |
First Address | Canyon, TX 79015-2544 |
Second Address | Canyon, TX 79015-2545 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/06/2005 |
Last Update Date | 18/10/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
037631101 | (05) | TX |
070002897 | MEDICARE RAILROAD (01) | TX |
807985 | BLUE CROSS BLUE SHIELD (01) | TX |