Provider Demographics
NPI:1538415583
Name:ROBERTSON, TIMOTHY WAYNE JR (LSA, CSA)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:WAYNE
Last Name:ROBERTSON
Suffix:JR
Gender:M
Credentials:LSA, CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4427 N VINEYARD MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77449-3445
Mailing Address - Country:US
Mailing Address - Phone:832-248-8635
Mailing Address - Fax:
Practice Address - Street 1:4427 N VINEYARD MEADOW LN
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77449-3445
Practice Address - Country:US
Practice Address - Phone:832-248-8635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-27
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00487363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXSA00487OtherN/A