Provider Demographics
NPI:1144483090
Name:ROBLES, BERTHA IZAURA (PA-C)
Entity type:Individual
Prefix:
First Name:BERTHA
Middle Name:IZAURA
Last Name:ROBLES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 HOSPITAL DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MCKENZIE
Mailing Address - State:TN
Mailing Address - Zip Code:38201
Mailing Address - Country:US
Mailing Address - Phone:731-352-7907
Mailing Address - Fax:731-352-4459
Practice Address - Street 1:205 HOSPITAL DR STE A
Practice Address - Street 2:
Practice Address - City:MC KENZIE
Practice Address - State:TN
Practice Address - Zip Code:38201-1649
Practice Address - Country:US
Practice Address - Phone:731-352-7907
Practice Address - Fax:731-352-4459
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA1621363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
3380640OtherMEDICAID GROUP
TN1507308Medicaid
TNPA1621OtherPROFESSIONAL LICENSE
TN3665275Medicare PIN
TN3665275Medicare PIN