Provider Demographics
NPI:1215285366
Name:ROBERTSON, JOEL (PA)
Entity type:Individual
Prefix:MR
First Name:JOEL
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2645 ILLINOIS CT
Mailing Address - Street 2:
Mailing Address - City:GREEN RIVER
Mailing Address - State:WY
Mailing Address - Zip Code:82935-6131
Mailing Address - Country:US
Mailing Address - Phone:307-399-3037
Mailing Address - Fax:
Practice Address - Street 1:1400 UINTA DR
Practice Address - Street 2:
Practice Address - City:GREEN RIVER
Practice Address - State:WY
Practice Address - Zip Code:82935-5060
Practice Address - Country:US
Practice Address - Phone:307-872-4500
Practice Address - Fax:307-872-4595
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-21
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant