MEDICARE: MR. GRANT D ROBERTS PA

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	1204	OK
2	363AS0400X	Surgical Physician Assistant	1204	OK

General Provider Information

NPI Number	:	1336111483
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GRANT D ROBERTS PA

Provider Business Mailing Address
First Line	:	14024 QUAIL POINTE DR
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73134-1006
Country	:	US
Telephone Number	:	405-419-8447
Fax Number	:	405-419-7745

Provider Business Practice Location Address
First Line	:	3110 SW 89TH ST STE 102
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-7919
Country	:	US
Telephone Number	:	405-703-4950
Fax Number	:	405-703-4955

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

Provider Enumeration Date	:	02/03/2006
Last Update Date	:	07/24/2015

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