MEDICARE: EDWARD HARRY ROBERTSON JR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator	AB178286H	ID

General Provider Information

NPI Number	:	1235063876
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWARD HARRY ROBERTSON JR.

Provider Business Mailing Address
First Line	:	3510 S BIG LOST CT
Second Line	:
City	:	NAMPA
State	:	ID
Zip	:	83686-5173
Country	:	US
Telephone Number	:	208-270-0427
Fax Number	:

Provider Business Practice Location Address
First Line	:	3510 S BIG LOST CT
Second Line	:
City	:	NAMPA
State	:	ID
Zip	:	83686-5173
Country	:	US
Telephone Number	:	208-270-0427
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2026
Last Update Date	:	06/09/2026

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