Provider Demographics
NPI:1679005599
Name:ROBERTSON, DAVID (RN)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 RS COUNTY ROAD 2400
Mailing Address - Street 2:
Mailing Address - City:EMORY
Mailing Address - State:TX
Mailing Address - Zip Code:75440
Mailing Address - Country:US
Mailing Address - Phone:903-521-8826
Mailing Address - Fax:
Practice Address - Street 1:10013 JOES BAYOU RD
Practice Address - Street 2:
Practice Address - City:BAY ST LOUIS
Practice Address - State:MS
Practice Address - Zip Code:39520-1702
Practice Address - Country:US
Practice Address - Phone:601-422-9626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-30
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175F00000X
MSR855938163W00000X
TX1036322163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered Nurse
No175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty
No163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Multi-Specialty