Provider Demographics
NPI:1063539070
Name:ROBERTSON, THOMAS (RN)
Entity type:Individual
Prefix:
First Name:THOMAS
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 1:421 S KEECH ST
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-4623
Mailing Address - Country:US
Mailing Address - Phone:386-238-4980
Mailing Address - Fax:
Practice Address - Street 1:421 S KEECH ST
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-4623
Practice Address - Country:US
Practice Address - Phone:386-238-4980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9169753163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL312001500Medicaid