Provider Demographics
NPI:1124275276
Name:ROBERTS, MARILYN (RPA)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:RPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6560 WESTMONT AVE
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-9100
Mailing Address - Country:US
Mailing Address - Phone:909-244-0658
Mailing Address - Fax:909-244-9198
Practice Address - Street 1:8283 GROVE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3137
Practice Address - Country:US
Practice Address - Phone:909-982-8638
Practice Address - Fax:909-982-9618
Is Sole Proprietor?:No
Enumeration Date:2008-08-20
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT08 FL 1335243U00000X
CARHF 94132247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes243U00000XTechnologists, Technicians & Other Technical Service ProvidersRadiology Practitioner Assistant
No247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist