Provider Demographics
NPI:1245651512
Name:ROBERTS, MIA WALLIN (CPNP)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:WALLIN
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13120 E 19TH AVE C288-5
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80045
Mailing Address - Country:US
Mailing Address - Phone:303-724-8555
Mailing Address - Fax:303-724-4729
Practice Address - Street 1:4107 S FEDERAL BLVD STE B
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80110-4316
Practice Address - Country:US
Practice Address - Phone:303-315-6150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07790363LP0200X
COAPN.0990539-NP363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CORXN-0100826-NPOtherPRESCIPTIVE AUTHORITY IDENTIFICATION NUMBER