Healthcare Provider Details

I. General information

NPI: 1215285366
Provider Name (Legal Business Name): JOEL ROBERTSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2012
Last Update Date: 06/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 UINTA DR
GREEN RIVER WY
82935-5060
US

IV. Provider business mailing address

2645 ILLINOIS CT
GREEN RIVER WY
82935-6131
US

V. Phone/Fax

Practice location:
  • Phone: 307-872-4500
  • Fax: 307-872-4595
Mailing address:
  • Phone: 307-399-3037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: