Provider Demographics
NPI:1316689441
Name:ROBERTS, GABRIEL ISAAC (PA-C)
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:ISAAC
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1097A COOK RD
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-8209
Mailing Address - Country:US
Mailing Address - Phone:803-395-3370
Mailing Address - Fax:
Practice Address - Street 1:1097A COOK RD
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-8209
Practice Address - Country:US
Practice Address - Phone:803-395-3370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-09
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMPA.4368208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty