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General NPI Number Information
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NPI Number | 1588094825
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Entity Type | Individual
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Provider Name | MARK ROBERTS
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Gender | Male
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Dates
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Enumeration Date | 11/23/2013
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Last Update Date | 10/14/2024
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Provider Practice Location Address
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Address Line | 122 WYOMING ST
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City | DAYTON
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State | OH
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Zip | 45409-2731
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Country | US
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Telephone | 937-223-4461
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Fax | 937-449-7603
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Provider Business Mailing Address
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Address Line | 1846 SPINDLETOP LN
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City | DAYTON
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State | OH
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Zip | 45458-6501
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Country | US
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Telephone | 937-991-3188
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Fax | 937-223-9811
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 164W00000X
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Taxonomy Name | Licensed Practical Nurse
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License Number | PN151753-M-IV
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | APRN.CNP.0027441
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License Number State | OH
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Taxonomy #3
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | APRN.CNP.0027441
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License Number State | OH
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