Provider Demographics
NPI:1144485533
Name:ROBERTS, MARY JEANNE (AA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JEANNE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:JEANNE
Other - Last Name:HLADKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AA
Mailing Address - Street 1:PO BOX 804408
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-4408
Mailing Address - Country:US
Mailing Address - Phone:913-642-4900
Mailing Address - Fax:913-381-0979
Practice Address - Street 1:2525 GLENN HENDREN DR
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-9625
Practice Address - Country:US
Practice Address - Phone:816-792-7126
Practice Address - Fax:816-792-7196
Is Sole Proprietor?:No
Enumeration Date:2008-07-24
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008016062367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00639280OtherRR MEDICARE
MO1144485533Medicaid
MO452000006Medicare PIN