Healthcare Provider Details

I. General information

NPI: 1639294283
Provider Name (Legal Business Name): MELISSA DIANE ROBERTS P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 01/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3651 WHEELER RD
AUGUSTA GA
30909-6521
US

IV. Provider business mailing address

318 SAINT ANDREWS DR
AUGUSTA GA
30909-7804
US

V. Phone/Fax

Practice location:
  • Phone: 706-651-3232
  • Fax:
Mailing address:
  • Phone: 706-589-0520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number4358
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: