Provider Demographics
NPI:1063623320
Name:ROBERTSON, TANIA (MD)
Entity type:Individual
Prefix:DR
First Name:TANIA
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 RYAN AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-5591
Mailing Address - Country:US
Mailing Address - Phone:559-307-8879
Mailing Address - Fax:
Practice Address - Street 1:354 SANTA FE DR
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-5142
Practice Address - Country:US
Practice Address - Phone:760-230-2251
Practice Address - Fax:760-230-2253
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA89334207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA893334AMedicare PIN