Healthcare Provider Details

I. General information

NPI: 1770718298
Provider Name (Legal Business Name): PAUL ROBERTSON MS, RDN, LDN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2009
Last Update Date: 01/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 WEST WOODROW WILSON AVENUE AMBULATORY SERVICES - OUTPATIENT DIETITIAN
JACKSON MS
39213
US

IV. Provider business mailing address

350 WEST WOODROW WILSON AVENUE AMBULATORY SERVICES - OUTPATIENT DIETITIAN
JACKSON MS
39213
US

V. Phone/Fax

Practice location:
  • Phone: 601-815-2500
  • Fax: 601-984-4074
Mailing address:
  • Phone: 601-815-2500
  • Fax: 601-984-4074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberD1361
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: