Provider Demographics
NPI:1730453283
Name:ROBERTS, SUSAN TRACY (NP-C)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:TRACY
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1661 TURNER SPUR RD
Mailing Address - Street 2:
Mailing Address - City:FANCY GAP
Mailing Address - State:VA
Mailing Address - Zip Code:24328-4365
Mailing Address - Country:US
Mailing Address - Phone:276-728-0735
Mailing Address - Fax:276-728-7717
Practice Address - Street 1:1661 TURNER SPUR RD
Practice Address - Street 2:
Practice Address - City:FANCY GAP
Practice Address - State:VA
Practice Address - Zip Code:24328-4365
Practice Address - Country:US
Practice Address - Phone:276-728-0735
Practice Address - Fax:276-728-7717
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-01
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5006199363LX0106X
VA0024169878363L00000X, 207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational HealthGroup - Single Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA363L00000XOtherTAXONOMY