MEDICARE: ROBERTA WASHBURN

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	133V00000X	Registered Dietitian	DT03892	TX
2	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1588139810
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERTA WASHBURN

Provider Business Mailing Address
First Line	:	2205 ENCINO CLIFF ST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78259-2417
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2205 ENCINO CLIFF ST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78259-2417
Country	:	US
Telephone Number	:	210-497-5629
Fax Number	:

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

Provider Enumeration Date	:	10/13/2018
Last Update Date	:	10/13/2018

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