Provider Demographics
NPI:1679283360
Name:ROBERTS, PARKER RICHARD
Entity type:Individual
Prefix:
First Name:PARKER
Middle Name:RICHARD
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2221 LAKESIDE BLVD STE 600
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-4416
Mailing Address - Country:US
Mailing Address - Phone:469-505-1652
Mailing Address - Fax:469-436-3976
Practice Address - Street 1:5475 S 500 E
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6905
Practice Address - Country:US
Practice Address - Phone:800-880-3566
Practice Address - Fax:801-432-2670
Is Sole Proprietor?:No
Enumeration Date:2022-12-02
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10397447-3102163W00000X
UT103974474406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse