MEDICARE: GABRIEL ISAAC ROBERTS 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	MPA.4368	SC

General Provider Information

NPI Number	:	1316689441
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GABRIEL ISAAC ROBERTS PA-C

Provider Business Mailing Address
First Line	:	1097A COOK RD
Second Line	:
City	:	ORANGEBURG
State	:	SC
Zip	:	29118-8209
Country	:	US
Telephone Number	:	803-395-3370
Fax Number	:

Provider Business Practice Location Address
First Line	:	1097A COOK RD
Second Line	:
City	:	ORANGEBURG
State	:	SC
Zip	:	29118-8209
Country	:	US
Telephone Number	:	803-395-3370
Fax Number	:

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

Provider Enumeration Date	:	04/09/2022
Last Update Date	:	06/26/2026

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