Healthcare Provider Details

I. General information

NPI: 1720595457
Provider Name (Legal Business Name): JOHN WILLIAM ROBERTS II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2018
Last Update Date: 01/17/2023
Certification Date: 01/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 18TH ST E
TIFTON GA
31794-3648
US

IV. Provider business mailing address

420 HANSELL SEARS RD
DOUGLAS GA
31535-5720
US

V. Phone/Fax

Practice location:
  • Phone: 229-382-7120
  • Fax:
Mailing address:
  • Phone: 912-592-0765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN230702
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number090060-23
License Number StateNH
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN230702
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: