Provider Demographics
NPI:1104591825
Name:ROBERTS, MARQUIS (RN)
Entity type:Individual
Prefix:
First Name:MARQUIS
Middle Name:
Last Name:ROBERTS
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 1:385 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:GROVER BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93433-2344
Mailing Address - Country:US
Mailing Address - Phone:757-879-7945
Mailing Address - Fax:
Practice Address - Street 1:400 E OAK AVE
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-5034
Practice Address - Country:US
Practice Address - Phone:877-960-3426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-13
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA832164163WE0003X
CA95019607363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency