Provider Demographics
NPI:1316259138
Name:ROBERTS, MICHELLE GEANY (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:GEANY
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:LYN
Other - Last Name:GEANY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:300 LONGWOOD AVE
Mailing Address - Street 2:LO367
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115
Mailing Address - Country:US
Mailing Address - Phone:617-355-6460
Mailing Address - Fax:
Practice Address - Street 1:300 LONGWOOD AVENUE
Practice Address - Street 2:LO367
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115
Practice Address - Country:US
Practice Address - Phone:617-355-6460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-09
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA3941363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical