Provider Demographics
NPI:1134428923
Name:ROBERSON, TYRONE G SR (AGPCNP-BC)
Entity type:Individual
Prefix:MR
First Name:TYRONE
Middle Name:G
Last Name:ROBERSON
Suffix:SR
Gender:M
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6439 GARNERS FERRY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209
Mailing Address - Country:US
Mailing Address - Phone:803-776-4000
Mailing Address - Fax:
Practice Address - Street 1:6439 GARNERS FERRY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209
Practice Address - Country:US
Practice Address - Phone:803-776-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-20
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC69630163WE0003X
SCPR27111164W00000X
SC19344363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
No164W00000XNursing Service ProvidersLicensed Practical Nurse