MEDICARE: MRS. NATISHA LATRISE ROBERSON-DUNN 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	363AM0700X	Medical Physician Assistant	004412	GA

General Provider Information

NPI Number	:	1285818567
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NATISHA LATRISE ROBERSON-DUNN PA-C

Provider Business Mailing Address
First Line	:	15 COBBLESTONE DR
Second Line	:
City	:	NEWNAN
State	:	GA
Zip	:	30265-6047
Country	:	US
Telephone Number	:	770-304-3932
Fax Number	:

Provider Business Practice Location Address
First Line	:	195 FAIRVIEW RD
Second Line	:
City	:	ELLENWOOD
State	:	GA
Zip	:	30294-2722
Country	:	US
Telephone Number	:	770-507-0112
Fax Number	:

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

Provider Enumeration Date	:	12/22/2007
Last Update Date	:	12/22/2007

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