Healthcare Provider Details

I. General information

NPI: 1407294424
Provider Name (Legal Business Name): NATALIE MARIE ROBERTS P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2013
Last Update Date: 06/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 N MAIN ST
MANTI UT
84642-1257
US

IV. Provider business mailing address

HC 13 BOX 4325
WALES UT
84667-5002
US

V. Phone/Fax

Practice location:
  • Phone: 435-835-3344
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6599981-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: