Provider Demographics
NPI:1215128335
Name:ROBERSON, CHARLEZETTA (PA)
Entity type:Individual
Prefix:MS
First Name:CHARLEZETTA
Middle Name:
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3211 W CHARLESTON BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1953
Mailing Address - Country:US
Mailing Address - Phone:702-871-3730
Mailing Address - Fax:702-871-7379
Practice Address - Street 1:360 S LOLA LN BLDG B
Practice Address - Street 2:
Practice Address - City:PAHRUMP
Practice Address - State:NV
Practice Address - Zip Code:89048-0884
Practice Address - Country:US
Practice Address - Phone:775-505-0810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV546363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV546OtherPA LICENSE
NV1215128335Medicaid
NVP8422Medicare UPIN
NVV84222Medicare PIN