MEDICARE: CLAYTON ERNEST ROBERTSON ATP

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	247200000X	Other Technician

General Provider Information

NPI Number	:	1518517762
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLAYTON ERNEST ROBERTSON ATP

Provider Business Mailing Address
First Line	:	5555 N LAMAR BLVD STE D113
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78751-1075
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5555 N LAMAR BLVD STE D113
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78751-1075
Country	:	US
Telephone Number	:	512-993-8871
Fax Number	:

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

Provider Enumeration Date	:	09/18/2019
Last Update Date	:	09/18/2019

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