MEDICARE: ANTHONY TYLER ROBERTSON PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	2660	OK

General Provider Information

NPI Number	:	1215362348
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTHONY TYLER ROBERTSON PA-C

Provider Business Mailing Address
First Line	:	1701 S DOUGLAS BLVD
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73130-6221
Country	:	US
Telephone Number	:	405-302-8999
Fax Number	:	405-733-9360

Provider Business Practice Location Address
First Line	:	1701 S DOUGLAS BLVD
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73130-6221
Country	:	US
Telephone Number	:	405-302-8999
Fax Number	:	405-733-9360

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/09/2013
Last Update Date	:	05/09/2017

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