Healthcare Provider Details

I. General information

NPI: 1104591825
Provider Name (Legal Business Name): MARQUIS ROBERTS RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2021
Last Update Date: 01/21/2022
Certification Date: 01/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E OAK AVE
VISALIA CA
93291-5034
US

IV. Provider business mailing address

385 S 8TH ST
GROVER BEACH CA
93433-2344
US

V. Phone/Fax

Practice location:
  • Phone: 877-960-3426
  • Fax:
Mailing address:
  • Phone: 757-879-7945
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number832164
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95019607
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: