Healthcare Provider Details

I. General information

NPI: 1902629785
Provider Name (Legal Business Name): EVANGELINE ROSE ROBERTSHAW PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2024
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6640 ALTON PKWY
IRVINE CA
92618-3734
US

IV. Provider business mailing address

3430 E LA PALMA AVE
ANAHEIM CA
92806-2020
US

V. Phone/Fax

Practice location:
  • Phone: 833-574-2273
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number085010895
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: