MEDICARE: KANEDRA KIARA ROBERTS

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

General Provider Information

NPI Number	:	1588421705
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KANEDRA KIARA ROBERTS

Provider Business Mailing Address
First Line	:	3600 GASTON AVENUE
Second Line	:	WADLEY TOWER, SUITE 1158
City	:	DALLAS
State	:	TX
Zip	:	75246
Country	:	US
Telephone Number	:	469-800-9290
Fax Number	:

Provider Business Practice Location Address
First Line	:	3600 GASTON AVE
Second Line	:	WADLEY TOWER, SUITE 1158
City	:	DALLAS
State	:	TX
Zip	:	75246-1800
Country	:	US
Telephone Number	:	469-800-9290
Fax Number	:

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

Provider Enumeration Date	:	03/04/2024
Last Update Date	:	06/14/2026

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