Healthcare Provider Details

I. General information

NPI: 1780044610
Provider Name (Legal Business Name): DANIEL S ROBERSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2016
Last Update Date: 05/24/2024
Certification Date: 05/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1371 CHURCH STREET EXT NE STE 200
MARIETTA GA
30060-7913
US

IV. Provider business mailing address

1551 JANMAR RD
SNELLVILLE GA
30078-5606
US

V. Phone/Fax

Practice location:
  • Phone: 678-344-8900
  • Fax: 678-666-5201
Mailing address:
  • Phone: 470-579-5600
  • Fax: 229-436-4107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number7920
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: